European Observatory on Health Systems and Policies Series
Primary care in the
driver’s seat?
Organizational reform in European primary care
Edited by
Richard B. Saltman
Ana Rico
Wienke Boerma
Primary care in the
driver’s seat?
The European Observatory on Health Systems and Policies is a partnership
between the WHO Regional Office for Europe, the Governments of Belgium,
Finland, Greece, Norway, Spain and Sweden, the Veneto Region of Italy,
the European Investment Bank, the Open Society Institute, the World Bank,
CRP-Santé Luxembourg, the London School of Economics and Political
Science (LSE), and the London School of Hygiene & Tropical Medicine (LSHTM).
This book was produced in collaboration with Nuffield Trust.
European Observatory on Health Systems and Policies Series
Edited by Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman
Primary care in the
driver’s seat?
Organizational reform in
European primary care
Edited by
Richard B. Saltman,
Ana Rico and
Wienke G. W. Boerma
Open University Press
Open University Press
McGraw-Hill Education
McGraw-Hill House
Shoppenhangers Road
Maidenhead
Berkshire
England
SL6 2QL
email: enquiries@openup.co.uk
world wide web: www.openup.co.uk
and Two Penn Plaza, New York, NY 10121–2289, USA
First published 2006
Copyright © World Health Organization 2006 on behalf of the European Observatory on Health
Systems and Policies.
The views expressed by authors or editors do not necessarily represent the decisions or the stated
policies of the European Observatory on Health Systems and Policies or any of its partners. The
designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the European Observatory on Health
Systems and Policies or any of its partners concerning the legal status of any country, territory,
city or area or of its authorities, or concerning the delimitations of its frontiers or boundaries.
Where the designation ‘country or area’ appears in the headings of tables, it covers countries,
territories, cities, or areas. Dotted lines on maps represent approximate border lines for which
there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the European Observatory on Health Systems and
Policies in preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters. The
European Observatory on Health Systems and Policies does not warrant that the information
contained in this publication is complete and correct and shall not be liable for any damages
incurred as a result of its use.
Rights to translate into German, Spanish, French and Russian should be sought from WHO at
WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen, Denmark or by email at
pubrights@euro.who.int. Rights to translate into all other world languages should be sought from
Open University Press.
All rights reserved. Except for the quotation of short passages for the purpose of criticism and
review, no part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior written permission of the publisher or a licence from the Copyright
Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be
obtained from the Copyright Licensing Agency Ltd of 90 Tottenham Court Road, London,
W1T 4LP.
A catalogue record of this book is available from the British Library
ISBN-10 0 335 21365 0 (pb) 0 335 21366 9 (hb)
ISBN-13 978 0 335 21365 8 (pb) 978 0 335 21366 5 (hb)
Library of Congress Cataloging-in-Publication Data
CIP data applied for
Typset by RefineCatch Limited, Bungay, Suffolk
Printed in the UK by Bell & Bain Ltd, Glasgow
European Observatory on Health Systems and Policies Series
The European Observatory on Health Systems and Policies is a unique
project that builds on the commitment of all its partners to improving health care
systems:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
World Health Organization Regional Office for Europe
Government of Belgium
Government of Finland
Government of Greece
Government of Norway
Government of Spain
Government of Sweden
Veneto Region
European Investment Bank
Open Society Institute
World Bank
CRP-Santé Luxembourg
London School of Economics and Political Science
London School of Hygiene and Tropical Medicine
The series
The volumes in this series focus on key issues for health policy-making in Europe. Each
study explores the conceptual background, outcomes and lessons learned about the
development of more equitable, more efficient and more effective health systems in
Europe. With this focus, the series seeks to contribute to the evolution of a more evidencebased approach to policy formulation in the health sector.
These studies will be important to all those involved in formulating or evaluating national
health care policies and, in particular, will be of use to health policy-makers and advisers,
who are under increasing pressure to rationalize the structure and funding of their health
system. Academics and students in the field of health policy will also find this series
valuable in seeking to understand better the complex choices that confront the health
systems of Europe.
The Observatory supports and promotes evidence-based health policy-making through
comprehensive and rigorous analysis of the dynamics of health care systems in Europe.
Series Editors
Josep Figueras is Head of the Secretariat and Research Director of the European Observatory
on Health Systems and Policies, and Head of the European Centre for Health Policy, World
Health Organization Regional Office for Europe.
Martin McKee is Research Director of the European Observatory on Health Systems and
Policies and Professor of European Public Health at the London School of Hygiene and
Tropical Medicine as well as a co-director of the School’s European Centre on Health of
Societies in Transition.
Elias Mossialos is Research Director of the European Observatory on Health Systems
and Policies, and Brian Abel-Smith Reader in Health Policy, Department of Social Policy,
London School of Economics and Political Science and co-director of LSE Health and
Social Care.
Richard B. Saltman is Research Director of the European Observatory on Health Systems
and Policies, and Professor of Health Policy and Management at the Rollins School of
Public Health, Emory University in Atlanta, Georgia.
European Observatory on Health Systems and
Policies Series
Series Editors: Josep Figueras, Martin McKee, Elias Mossialos
and Richard B. Saltman
Published titles
Health policy and European Union enlargement
Martin McKee, Laura MacLehose and Ellen Nolte (eds)
Regulating entrepreneurial behaviour in European health care systems
Richard B. Saltman, Reinhard Busse and Elias Mossialos (eds)
Social health insurance systems in Western Europe
Richard B. Saltman, Reinhard Busse and Josep Figueras (eds)
Health care in Central Asia
Martin McKee, Judith Healy and Jane Falkingham (eds)
Hospitals in a changing Europe
Martin McKee and Judith Healy (eds)
Funding health care: options for Europe
Elias Mossialos, Anna Dixon, Josep Figueras and Joe Kutzin (eds)
Regulating pharmaceuticals in Europe: striving for efficiency, equity and quality
Elias Mossialos, Monique Mrazek and Tom Walley (eds)
Purchasing to improve health systems performance
Joseph Figueras, Ray Robinson and Elke Jakubowski (eds)
Forthcoming titles
Mental health policy and practice across Europe
Martin Knapp, David McDaid, Elias Mossialos and Graham Thornicroft
(eds)
Human resources for health in Europe
Carl-Ardy Dubois, Martin McKee and Ellen Nolte (eds)
Contents
List of tables
List of boxes
List of figures
List of contributors
Series editors’ introduction
Foreword
Acknowledgements
ix
x
xi
xii
xv
xvii
xix
part one: Assessing the stragetic landscape
one
Coordination and integration in European
primary care
Wienke G.W. Boerma
3
two
Mapping primary care across Europe
Wienke G.W. Boerma and Carl-Ardy Dubois
three
Changing conditions for structural reform in
primary care
Wienke G. W. Boerma and Ana Rico
50
Drawing the strands together: primary care in
perspective
Richard B. Saltman
68
four
22
viii
Contents
part two: Changing institutional arrangements
five
six
seven
The challenge of coordination: the role of primary
care professionals in promoting integration across
the interface
Michael Calnan, Jack Hutten and Hrvoje Tiljak
The impact of primary care purchasing in Europe:
a comparative case study of primary care reform
Alison McCallum, Mats Brommels, Ray Robinson, Sven-Eric
Bergman and Toomas Palu
The evolving public-private mix
Rod Sheaff, Joan Gené-Badia, Martin Marshall and Igor Švab
85
105
129
Changing working arrangements
eight
Changing task profiles
Bonnie Sibbald, Miranda Laurant and Anthony Scott
nine
Changing professional roles in primary care
education
Jan Heyrman, Margus Lember, Valentin Rusovich and
Anna Dixon
ten
Managing primary care behaviour through
payment systems and financial incentives
Stefan Greß, Diana M. J. Delnoij and Peter P. Groenewegen
149
165
184
Changing quality standards
eleven
twelve
Improving the quality and performance of
primary care
Richard Baker, Michel Wensing and Bernhard Gibis
203
The role of new information and communication
technologies in primary care
Mårten Kvist and Michael Kidd
227
Index
245
List of tables
2.1 Number of GPs per 1000 population in European countries in
1990 and 2002
2.2 Number of full-time home helpers per 1000 population in
European countries
2A General practice: point of first contact care; generalist approach
and comprehensiveness
2B General practice: cooperation and continuity of care
2C General practice: medical equipment and diagnostic facilities; job
satisfaction
6.1 Models of primary care purchasing and devolved budgeting
9.1 The role of government, professionals and universities in PC
education
9.2 Human resources in PC across Europe
9.3 Specialty training in European countries: duration (years) by setting
9.4 Regulation of recertification in Europe
9.5 Features of CME and CPD in Europe
10.1 GP payment systems as of 2004 in 15 EU Member States and selected
accession states
11.1 Methods used to collect performance data in European countries in
1991–2 and 1994–5
11.2 Methods used to implement change in performance in European
countries, 1991–2 and 1994–5
11.3 Reviews of continuing education and quality improvement in
primary care
30
33
42
44
46
107
167
168
173
175
180
189
207
207
208
List of boxes
1.1
2.1
2.2
2.3
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
9.1
9.2
10.1
10.2
11.1
The Almere experiment
Finnish primary health centre
Family medicine in Romania
Slovenian primary care
Primary health provision in Spain
Personal Medical Service Schemes in England
Medical cooperatives in former Yugoslavia
Medical cooperatives for out-of-hours services in England
The Entitat de Base Asociativa, Catalonia
Integrated care structures in Germany
English Primary Care Trusts
Practice networks in Germany
Retraining in CCEE
Recertification in the United Kingdom
Mixed payment systems at the level of patients
Mixed payment systems at the level of GPs
Top-10 patient priorities regarding general practice in Europe
10
22
26
37
134
136
138
139
139
140
141
141
173
176
187
188
221
List of plates & figures
Plates (these appear in the plate section)
2.1
2.2
2.3
2.4
2.5
2.6
Density of GPs in Europe
Role of GPs as the doctor of first contact with health problems
Comprehensiveness of curative and preventive services by GPs
Collaboration of GPs with several disciplines
Medical equipment in general practice
GPs’ sense of satisfaction
Figures
10.1 Incentives of payment systems and of the health system context
for central values of primary care
11.1 The quality improvement cycle
12.1 Ten basic computing skills for health care professionals
12.2 Ten essential clinical informatics skills
192
205
237
238
List of contributors
Richard Baker is Professor and Head of the Department of Health Sciences at the
University of Leicester in Leicester, United Kingdom.
Sven-Eric Bergman is Consultant in Health Policy and Management at Bergman
and Dahlbäck AB in Stockholm, Sweden.
Wienke G. W. Boerma is Senior Researcher at NIVEL (The Netherlands Institute
for Health Services Research) in Utrecht, Netherlands.
Mats Brommels is Professor of Health Services Management at the University of
Helsinki, and Professor and Director of the Medical Management Centre at the
Karolinska Institute in Stockholm, Sweden.
Michael Calnan is Professor of Medical Sociology at the Department of Social
Medicine of the University of Bristol, United Kingdom.
Diana M. J. Delnoij is Senior Research Coordinator at NIVEL in Utrecht,
Netherlands.
Anna Dixon is Lecturer in European Health Policy at the Department of Social
Policy, London School of Economics and Political Science in London, United
Kingdom.
Carl-Ardy Dubois is Assistant Professor at the University of Montreal (Canada) in
the Faculty of Nursing Sciences.
List of contributors
xiii
Joan Gené-Badia is Family Doctor in the Castelldefels Primary Care Team at the
Catalan Institute of Health in Barcelona, Spain.
Bernhard Gibis is Director of the Department of Quality Assurance at the
National Association of Statutory Health Insurance Physicians (KBV) in Berlin,
Germany.
Stefan Greß is Assistant Professor at the Institute of Health Care Management of
the University of Duisburg-Essen in Essen, Germany.
Peter P. Groenewegen is Research Department Head at NIVEL and Professor of
Social and Geographical Aspects of Health and Health Care at Utrecht
University in Utrecht, Netherlands.
Jan Heyrman is Professor and Director of the Department of General Practice at
the Catholic University Leuven (KULeuven) in Leuven, Belgium.
Jack Hutten was Research Coordinator at NIVEL in Utrecht, Netherlands. At
present Senior Policy Advisor at the Curative Care Department of the Ministry
of Health, Welfare and Sports in The Hague, Netherlands.
Michael Kidd is Professor and Head of the Discipline of General Practice at the
University of Sydney, and President of The Royal Australian College of General
Practitioners in Sydney, Australia.
Mårten Kvist is Director of the Laitila-Pyhäranta Health Centre in Laitila,
Finland.
Miranda Laurant is Senior Researcher at the Centre for Quality of Care Research
of the Universities of Nijmegen and Maastricht in Nijmegen, Netherlands.
Margus Lember is Professor and Head of the Department of Internal Medicine at
the University of Tartu in Tartu, Estonia.
Martin Marshall is General Practitioner and Professor of General Practice at the
National Primary Care Research and Development Centre of the University of
Manchester in Manchester, United Kingdom.
Alison McCallum is Research Fellow, Outcomes and Equity Research, National
Research and Development Centre for Welfare and Health (STAKES) in Helsinki,
Finland, and Associate Professor at the Medical Management Centre of the
Karolinska Institute in Stockholm, Sweden.
Toomas Palu is Senior Health Specialist at the Europe and Central Asia Development Department of the World Bank in Washington DC, USA.
Ana Rico is Associate Professor of Health Politics and Policy at the Department of
Health Management and Economics of the University of Oslo, Norway.
Ray Robinson is Professor of Health Policy at the Health and Social Care Centre of
the London School of Economics and Political Science in London, United
Kingdom.
xiv
Primary care in the driver’s seat?
Valentin Rusovich is General Practitioner, Chairman of the Belarussian Association of General Practitioners and GP-teacher at the Department of General
Practice of the Belarussian Medical Academy for Continuous Medical Education
(BelMAPO), Department of General Practice in Minsk, Belarus.
Richard B. Saltman is Professor of Health Policy and Management at the Rollins
School of Public Health, Emory University in Atlanta, USA, and Research
Director of the European Observatory on Health Systems and Policies.
Anthony Scott is Reader in Health Economics at the Health Economics Research
Unit of the University of Aberdeen in Aberdeen, United Kingdom.
Rod Sheaff is Senior Research Fellow at the National Primary Care Research and
Development Centre of Manchester University in Manchester, United
Kingdom.
Bonnie Sibbald is Professor of Health Services Research at the National Primary
Care Research and Development Centre of the University of Manchester in
Manchester, United Kingdom.
Igor Švab is Professor and Head of the Department of Family Medicine at the
University of Ljubljana, Slovenia.
Hrvoje Tiljak is Senior Lecturer at the Andrija Štampar School of Public Health in
Zagreb, Croatia.
Michel Wensing is Senior Lecturer at the Centre for Quality of Care Research of
the Universities of Nijmegen and Maastricht in Nijmegen, Netherlands.
Series editors’ introduction
European national policy makers broadly agree on the core objectives that their
health care systems should pursue. The list is strikingly straightforward: universal access for all citizens, effective care for better health outcomes, efficient
use of resources, high-quality services and responsiveness to patient concerns. It
is a formula that resonates across the political spectrum and which, in various,
sometimes inventive, configurations, has played a role in most recent European
national election campaigns.
Yet this clear consensus can only be observed at the abstract policy level. Once
decision makers seek to translate their objectives into the nuts and bolts of
health system organization, common principles rapidly devolve into divergent,
occasionally contradictory, approaches. This is, of course, not a new phenomenon in the health sector. Different nations, with different histories, cultures
and political experiences, have long since constructed quite different institutional arrangements for funding and delivering health care services.
The diversity of health system configurations that has developed in response
to broadly common objectives leads quite naturally to questions about the
advantages and disadvantages inherent in different arrangements, and which
approach is ‘better’ or even ‘best’ given a particular context and set of policy
priorities. These concerns have intensified over the last decade as policy makers
have sought to improve health system performance through what has become a
Europe-wide wave of health system reforms. The search for comparative advantage has triggered – in health policy as in clinical medicine – increased attention
to its knowledge base, and to the possibility of overcoming at least part of existing institutional divergence through more evidence-based health policy making.
xvi
Primary care in the driver’s seat?
The volumes published in the European Observatory on Health Systems and
Policies series are intended to provide precisely this kind of cross-national
health policy analysis. Drawing on an extensive network of experts and policy
makers working in a variety of academic and administrative capacities, these
studies seek to synthesize the available evidence on key health sector topics
using a systematic methodology. Each volume explores the conceptual background, outcomes and lessons learned about the development of more equitable, more efficient and more effective health care systems in Europe. With this
focus, the series seeks to contribute to the evolution of a more evidence-based
approach to policy formulation in the health sector. While remaining sensitive
to cultural, social and normative differences among countries, the studies
explore a range of policy alternatives available for future decision making. By
examining closely both the advantages and disadvantages of different policy
approaches, these volumes fulfil central mandates of the Observatory: to serve
as a bridge between pure academic research and the needs of policy makers, and
to stimulate the development of strategic responses suited to the real political
world in which health sector reform must be implemented.
The European Observatory on Health Systems and Policies is a partnership
that brings together three international agencies, six national governments, a
region of Italy, two research institutions and an international nongovernmental
organization. The partners are as follows: the World Health Organization
Regional Office for Europe, which provides the Observatory secretariat; the
governments of Belgium, Finland, Greece, Norway, Spain and Sweden; the
Veneto Region; the European Investment Bank; the Open Society Institute;
the World Bank; the London School of Hygiene and Tropical Medicine and the
London School of Economics and Political Science.
In addition to the analytical and cross-national comparative studies
published in this Open University Press series, the Observatory produces
Health Care Systems in Transition (HiTs) profiles for the countries of Europe,
the journal EuroHealth and the newsletter EuroObserver. Further information
about Observatory publications and activities can be found on its web site,
www.observatory.dk.
Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman
Foreword
Primary care in Europe has grown dramatically in scope and respect over the
past several decades. This reflects a concerted effort by academics, policymakers, and national and international organizations to move primary care,
as a core component of primary health care, into the centre of health system
decision-making and responsibility. While the process has taken on different
forms in different countries, the underlying goal has been broadly similar.
This process of organizational change has been a difficult and complicated
exercise. In varying degrees, it has involved developing new and more balanced
relationships between hospital and primary care, between specialist and general
practitioner, between primary care and home care, and, in a number of
environments, between inpatient and outpatient forms of care. These types of
fundamental organizational adjustments are, by their very nature, long-term
endeavours. Progress must be counted in years and requires focused and persistent efforts from key actors.
This study serves as a status report on this process of organizational change.
Drawing on a broad range of information and perspectives, it charts primary
care’s progress to date in achieving what are important health policy objectives
for all of Europe’s health care systems. This progress is particularly notable in
the recent rapid proliferation of innovative mechanisms such as care networks
for the chronically ill and the elderly, and continuing experimentation with
new funding instruments to support and extend these networks.
The assessment provided in this volume closely follows the view of many
national policy-makers that Europe is in a period of extensive innovation in
primary care. This intellectual and organizational ferment, if sustained, can
xviii Primary care in the driver’s seat?
help close the gap between the expectations of health policy-makers about the
major role that primary care should play, on the one hand, and the day-to-day
performance of real health systems, on the other hand.
There are, to be certain, additional dilemmas that still remain to be addressed.
As the study rightly notes, some of the most important decisions about how
primary care can best be institutionalized within modern health care systems –
in particular the title’s question as to whether primary care ought to be in
the health system’s ‘driver’s seat’ – have yet to be determined. These decisions,
and the associated issues that go with them, will continue to be a central focus
of policy-making activity across Europe. Despite the undeniable reality that
primary care has come a long way from where it began in the 1970s, there
remains a great deal of work to be done if it is to achieve its full promise. In
outlining the extent of the overall progress that primary care has accomplished
to date, the reform innovations currently underway, and the complex issues yet
to be resolved, this volume provides both policy-makers and scholars with a
valuable perspective on this very important effort.
Marc Danzon
WHO Regional Director for Europe
Acknowledgements
The editors are grateful for generous contributions made to this project by
numerous individuals and organizations. We are heavily indebted to our chapter
authors, whose commitment of both time and knowledge made this study possible. We also thank John Wyn Owen and the Nuffield Trust for Research and
Policy Studies in Health Services for their support, and for their superb hosting
of the author’s workshop on 21–22 May 2002 in London. Additional thanks are
due to the external experts who joined us for that workshop: Martin Roland,
Mikko Vienonen, Milagros Garcia-Barbero, Oliver Gröne, and Philippe Duprat.
The final volume benefited greatly from the extensive comments on an early
draft by four external reviewers: Allen Hutchinson, Chris van Weel, Leon
Epstein, and Josep Goicoechea. Valuable suggestions for revision were made on
the first three chapters by staff members at NIVEL.
Expert research and editorial support was provided by the Observatory team
in Madrid – Hans Dubois, Marikay McCabe, and Wendy Wisbaum – with
additional typing support from Charlotte Brandigi in Atlanta. Coordination
with Open University Press/McGraw-Hill Education on the delivery and production process was provided by Francine Raveney and Nicole Satterley.
part
one
Assessing the strategic
landscape
chapter
one
Coordination and integration
in European primary care
Wienke G. W. Boerma
A book on stronger primary care
The title of this book appears to imply that the current driver of the health care
system is not doing a satisfactory job and should be replaced by primary care.
Indeed, it may be that in a number of European countries the provision of
health care to patients is inadequately steered, but this is likely due to the fact
that, too often, there seems to be nobody behind the wheel. This situation is not
new. In the 1970s and 1980s, countries sought with varying degrees of success
to make health services more efficient and more coherent (Abel-Smith and
Mossialos, 1994; Maynard and Bloor, 1995; Saltman and Figueras, 1997). Several
decades later, insufficient coherence and coordination in health care are still
considered the main causes of lack of responsiveness to the needs of the population. Experience in several countries indicates that this problem can be tackled
at the point where patients normally enter the health care system, where the
scope of the patients’ health problems is examined and where decisions are
made about other possible providers to involve: that is, in primary care (WHO,
2002). Strengthening primary care by extending the skill mix or giving primary
care control over other levels of care is often mentioned as key to the solution
(Starfield and Shi, 2002). How feasible are these ambitions in the current health
care context in Europe, which is extremely heterogeneous, particularly with
regard to primary care? What are the conditions for strong primary care and
what is known about effective measures and strategies? Although the organization and provision of health care are still largely a national affair, European
integration has led to higher interest in foreign experiences in the field of health
system development as the basis of policy-making (WHO, 2002).
The aim of this book is to consider the extent to which strengthening primary
care can be a suitable strategy to improve the overall coherence in health care
and to explore the conditions and instruments that fit into this strategy. The
4 Primary care in the driver’s seat?
“driver’s seat” in the book’s title refers to the coordination and navigation function, for which primary care may have considerable potential. After completing
our exploration we maintain the question mark in the title, however, because
the answer is not unequivocal. The character and conditions of primary care in
Europe are so diverse that a general judgement about the suitability of primary
care for coordination and navigation is hard to make.
This volume explores the different approaches to primary care found across
Europe and examines the success of different strategic alternatives in its design
and operation. In this introductory chapter, we set the conceptual stage for the
more detailed assessments that follow. We begin by examining the central issue
of health system coherence and coordination, and assessing the role that primary care might play in resolving this dilemma. Drawing on this analysis, we
then develop a working definition of primary care, which, in turn, serves as the
basis for Chapter Two’s subsequent mapping of primary care resources across
the European region.
The problem
Despite constantly rising health expenditures in European countries, the health
needs of growing subgroups of the population, such as the chronically ill, the
elderly and those in need of hospice services in their homes, are not well met
(McKee and Healy, 2001). Over the past years these needs have changed quantitatively and qualitatively and they will continue to do so, as a result of the epidemiological transition related to the ageing of populations and the general
increase in wealth in most countries. Larger proportions of patients suffer from
more than one disease and receive a mix of health (and social) care provided by
several workers from different disciplines at the same time (Van den Akker et al.,
1998; Menotti et al., 2001; Westert et al., 2001). Such complex needs often are not
adequately dealt with by a health care system which itself has also become much
more complex. The inadequacy may result not only in unmet needs, but also in
unnecessary treatments, medicalization and other threats to patients’ safety.
The increased system complexity is a side effect of specialization and subspecialization in health care, by which professional “inward-directedness” has
tended to grow at the expense of attention to integration with other disciplines.
The implementation of new care arrangements, such as those based on shared
care, substitution and teamwork, is hampered by this fragmentation. More
coordination will be needed to offer users of complex care the guidance and
navigation to find their way through the system. Problems of coordination are
likely to arise at key interfaces: between primary and secondary care, between
curative care and public health services, and between specialities within particular subsectors (Renders et al., 2001; Faulkner et al., 2003; Rat et al., 2004).
Another development that underlines the need for more coherence and
coordination is the growing importance of anticipatory medicine and prevention. These are expected to bring further population health gain in terms of
quality of life and life expectancy. Health care may be increasingly asked to look
actively and systematically for conditions in their early stages and to identify
factors that are known to be health risks. Screening, monitoring and follow-up,
Coordination and integration in European primary care 5
which are still relatively new tasks in primary care, can only be carried out
effectively by the coordinated the efforts of various professional groups on the
basis of information concerning the population they serve (Isles et al., 2000;
Murchie et al., 2003; Oakeshott et al., 2003; Campbell, 2004). Where preventive
interventions already go beyond the boundaries of standard health care,
extended coordination will be needed to include other sectors such as social
services or education.
The pressures for change originate not only from public dissatisfaction about
poor responsiveness of health care and the need to find effective ways of promoting health and preventing disease. Policy-makers, financers and others
responsible for health care expenditure have long worried about the growing
costs of health care (Abel-Smith, 1992; OECD, 1995). They are looking
for incentives and mechanisms to enhance accountability and the awareness
among health care providers of the common goal of efficiency. Currently, there
is demand for reform measures that can improve coordination across health
systems as well as stimulate a more efficient use of resources. Thus, current
pressures go beyond the more targeted cost-containment measures that were
dominant in the 1990s (OECD, 1995; Paton, 2000).
Although analysts tend to view health care as an integrated system, existing
arrangements do not always provide a well-organized response to the health
problems occurring in a society. The relevant characteristics of a system are not
evident: operational goals are not always shared, the division of labour is far
from perfect and, due to lack of coordination, the various elements of health
care lack coherence (Van der Zee et al., 2004). Poor communication between
primary care, hospitals, and medical specialists has been well documented in
many health care systems for decades. Similarly, curative health care and public
health services are usually worlds apart. Furthermore, status and domain problems may prevent good working relations between doctors and nurses, in particular if the latter are working in separate organizations, such as independent
practice and home care organizations (Poulton and West, 1993; Mur-Veeman
et al., 2001). Removing these barriers, for instance by creating incentives for
teamwork, may improve the quality of care at the individual and facility levels
of health care, but may not be sufficient to bring about increased coordination
among levels and sectors of care. Other specific measures will be needed to
establish new forms of supply that guarantee seamless interfaces, such as chains
of care or integrated care networks.
Primary care: features and disciplines
Definitions of primary care are numerous and either more descriptive or normative, depending on the purpose they serve. The normative approach has been
closely connected with the WHO Alma Ata Declaration in 1978 on Primary
Health Care, in which the focus was on solidarity and equitable access to care;
on the protection and promotion of health rather than on curing illness; on
more influence of the population on health care instead of professional dominance; and on broad intersectoral collaboration in dealing with community
problems (WHO, 1978).
6 Primary care in the driver’s seat?
Although the concepts of “primary care” and “primary health care” are often
used as synonyms, they represent different aspects of the development and
articulation of first level care. The subject of this book is not the broad societal
strategy of primary health care as laid out at Alma Ata, but rather the more
limited area of primary care as a subset of functions or services delivered specifically within the context of health care systems. Of course, a well-designed primary care sector can also serve broader primary health care goals as well. In the
current European context of health care, the concept of primary care can be
understood in the following ways: as refering to a level of care between informal
care and hospital care; or to a set of functions and activities; or to a means of
performing those functions and activities; or to a set of characteristics for the
organization of health services (Starfield, 1992, 1998). One consistent thread
within these variations is that primary care consists of the professional response
when patients make first contact with the health care system. This approach
to primary care is considerably broader than the care delivered by a general
practitioner or a family doctor, yet is considerably more restricted than the
intersectoral concept of primary health care promulgated at Alma Ata. It is precisely this intermediate category, however, which is at the centre of ongoing
primary care development in many European countries (see as examples the
four boxes in this chapter and Chapter Two) and which is the focal point for
efforts to improve coherence and coordination in health care service delivery.
For the purposes of this book, we will refer to this intermediate category as
‘extended primary care.’ As an initial step in the formulation of a working definition, we will address the functions or attributes of extended primary care, since
they help identify which patients need adequate help, once they have taken the
step to seek professional health care services.
The primary care process
Although the manifestations of primary care in Europe are diverse and the
disciplines involved differ, its functions can be identified in most health care
systems, although to differing degrees (Boerma, 2003; Raad voor de Volksgezondheid en Zorg, 2004). The most evident primary care function is serving as
the point patients receive first contact professional care. This point lies at the
transition from lay care to professional care, where a general identification of
the problem takes place. Information about the previous visits of this patient
and his or her medical history is taken into account. It may be necessary then to
clarify the demand: what does the patient (actually) expect from health care and
what are the patient’s own options for dealing with the problem? At this stage
already, large proportions of demands appear not to need further intervention
and it will suffice to give information, reassurance or advice, sometimes combined
with a follow-up appointment. For other patients a diagnostic procedure may be
required. Diagnostic examinations will focus particularly on the identification
or exclusion of severe illness. The diagnostic phase may be followed by treatment. Decisions on treatment are taken together with the patients because their
motivation and possibilities are determinants of success. Depending on the kind
of treatment it may be necessary to involve other disciplines, either in primary care
Coordination and integration in European primary care 7
or in secondary care. Involvement may vary from asking for advice to complete
referral. If more than one health professional or health care facility is involved
in the treatment, coordination is needed to avoid duplication and safeguard the
continuity of the treatment. Closely related to the functions mentioned so far,
which mainly apply to curative care, is prevention in primary care, which may
start from knowledge about patients and their living situation and observations
(weight or blood pressure, for instance) made during curative contacts. The
preventive function may also extend to groups in the community.
The attributes or functions of primary care have been concisely summarized
in the definition of the American Institute of Medicine (Donaldson et al., 1996)
referring to “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care
needs, developing a sustained partnership with patients and practicing in the
context of family and community”. Needless to say, the functions attributed to
primary care may also apply to varying degrees to other levels of care.
Other dimensions
As a level of care, primary care is often represented as the base of the pyramid of
health care. The middle layer is secondary care while tertiary care is situated at
the top of the pyramid. Informal care is an unspecified area below the pyramid.
Primary care is the response to unspecified and common health problems
accounting for the vast majority of the population’s health needs. Problems that
require more specialized medical expertise are dealt with in secondary care, in
hospitals or the outpatient context, while rare and very complex cases are
treated in tertiary care (Fry, 1972). By the characteristics of their services, primary
care is the kind of care that is ambulatory and directly accessible to patients,
with a generalist character, situated in the community that it serves and with a
focus on the individual in his or her home situation and social context (Van der
Zee, 1989; Gervas et al., 1994). Starfield has defined primary care more in the
content and the range of care, including its integrative function: those services
addressing the most common problems by providing a mix of preventive, curative and rehabilitative services; integrating care when more than one health
problem exists, dealing with the context of illness; organizing and rationalizing
the deployment of basic and specialized resources (Starfield, 1991).
Primary care is not a discipline itself, but it is provided by professionals with
specialized training. Examining health care systems, disciplines can be listed
which are, to varying extents, involved in the provision of extended primary
care.
Primary care and general practice
A core discipline in primary care is general practice or family medicine. Primary
care started to develop in medical territory not occupied by (medical) specialists.
As specialization expanded and the number of specialties grew in the second
half of the twentieth century, these “residual activities” became labelled as
8
Primary care in the driver’s seat?
primary care and further developed to become its own specialty. In the
Netherlands, for example, primary care was officially identified as a separate
echelon in 1974 with the publication of a white paper on the structure of health
care. The paper concluded that health care was not coherent, the financing
fragmented and that too much emphasis was placed on the inpatient sector.
(Ministerie van Volksgezondheid en Milieuhygiëne, 1974). In 1980 another
paper, exclusively devoted to primary care, described the features of this echelon,
the health professions involved, and launched measures to strengthen primary
care (Ministerie van Volksgezondheid en Milieuhygiëne, 1980).
In Europe, primary care is not easily conceptualized without general practice,
but these two concepts are not equivalent. The concept of extended primary
care, as already noted, encompasses considerably more than general practice
alone. How much more varies from one country to another. In those countries
where general practice is well developed, the functions and characteristics of
primary care largely overlap with those of general practice, and general practice
may have a preferred position in primary care. In other countries, directly
accessible primary medical care is also provided by specialists, such as paediatricians, gynaecologists, specialists in internal medicine and cardiologists. A
definition of the general practitioner (GP), set out more than 30 years ago by the
British Royal College of General Practitioners, covers many of these elements.
According to this definition, a GP is
. . . a doctor who provides personal, primary and continuing medical care to
individuals and families. He may attend his patients in their own homes, in
his consulting room or sometimes in hospital. He accepts the responsibility
for making an initial decision on every problem his patient may present to
him, consulting with specialists when he thinks it appropriate to do so. He
will usually work in a group with other general practitioners, from premises
that are built or modified for the purpose, with the help of paramedical
colleagues, adequate secretarial staff and all the equipment which is necessary. Even if he is in a single-handed practice, he will work in a team and
delegate when necessary. His diagnosis will be composed in physical, psychological and social terms. He will intervene educationally, preventively
and therapeutically to promote his patient’s health.
(RCGP, 1972)
From this and the many definitions that came after, the following key characteristics of general practice or family medicine can be synthesized. First, it is
generalistic care, meaning that it deals with the full range of unselected health
problems and with all categories of the population, without exclusion on the
grounds of age or gender. Second, as the provider of first contact care, services are
available at all times and at a close proximity, in patients’ homes, if necessary.
Third, the orientation to the patients’ context implies that the individuality of a
patient is taken into account in the treatment as well as social network and
living circumstances. Fourth, the focus is on continuity: the interventions are not
limited to one episode of care but cover patients’ health needs longitudinally.
Fifth, comprehensiveness refers to the fact that services comprise curative,
rehabilitative and supportive care, as well as health promotion and disease prevention. Finally, coordination means that patients are referred to other health
Coordination and integration in European primary care 9
professionals if necessary and that health care resources are properly allocated
(Leeuwenhorst Group, 1974; WONCA, 1991, 2002; Boerma and Fleming, 1998;
Van Weel, 1999; Olesen, 2002; Boerma, 2003). From this characterization, it
follows clearly that general practice requires teamwork and collaboration with
other disciplines.
Other disciplines in primary care
As in other sectors, the professional division of tasks and specialization have
resulted in an increasing number of disciplines working in or with primary care.
Obviously, not all characteristics of primary care – for instance the direct accessibility or a general approach – apply equally to all disciplines in every health
care system in Europe. Furthermore, disciplines may be involved in primarycare-style activities but in hospitals or nursing homes as well. The typical profile
of involvement of various disciplines in primary care is a distinguishing feature
of the health care system in a country. In addition to general practice, the health
professions outlined below can be regarded as the major providers of primary
care (Boerma et al., 1993; Bower and Sibbald, 2004; Pringle and Irvine, 2004;
Raad voor de Volksgezondheid en Zorg, 2004).
Nursing is a crucial profession, which currently appears in primary care in
various forms (Kinnersley et al., 2000; Temmink et al., 2000; Pringle and Irvine,
2004). The longest tradition involves community nurses (or district nurses), who
care for patients in the home situation, mostly the very young, the elderly and
those with chronic conditions. Examples of this type of care include washing
patients, caring for wounds, administering medicines, giving information and
support, and technical interventions after hospitalization or in a terminal
phase. Psychiatric patients living at home are the target population of community psychiatric nurses. Activities of practice nurses include health promotion,
perinatal care, vaccinations and routine monitoring of the chronically ill in the
context of general practice. There is a tendency to involve practice nurses more
in patient management (Shum et al., 2000). In addition to the activities of practice nurses, nurse practitioners do certain diagnostic procedures and treatments
including administering some medication. In addition, other nurse specialists are
working in primary care teams for particular categories of patients, such as those
with diabetes, asthma and coronary heart diseases (Calnan et al., 1994; Vrijhoef,
2002).
The core task of pharmacists is to prepare and distribute of medicines prescribed by physicians. The density of pharmacists (and so their competition)
varies greatly among European countries. In a number of countries, especially
those where patients are usually registered with a pharmacy, providing patients
and general practitioners with information has become an important task for
pharmacies. Potentially, pharmacies are in a good position to develop a drugprescribing policy with GPs in their area and to keep a careful watch on the
safety of prescriptions (Hughes and McCann, 2003; Muijrers et al., 2004; Silcock
et al., 2004). In the Netherlands cooperation between GPs and pharmacists has
been strongly promoted since the early 1990s. Nowadays 71% of Dutch GPs
have an explicit agreement with a pharmacist concerning their prescription
10 Primary care in the driver’s seat?
policy. On average, Dutch GPs have meetings with pharmacists for 19 minutes
per week (Braspenning et al., 2004).
Physiotherapy is a rapidly growing profession in some countries, particularly in
north-western Europe. Physiotherapists treat patients with musculoskeletal
problems and they may work in institutions or in the community. In some
countries patients may need a referral from a physician to see a physiotherapist
(Koster et al., 1991).
Midwifery is usually practiced in a clinical setting, where midwives are involved
in prenatal care and deliveries under the supervision of obstetricians. In some
countries midwives also work in the community (Page, 2001). In the Netherlands they have a unique position: midwives are responsible for about 40% of all
deliveries most of which are at home (Wiegers et al., 1998).
Finally, there are some disciplines with primary care functions although these
workers are not always classified as primary care. Most important are home helpers, who give personal and domestic assistance, often in situations where community nurses also are involved (Hutten and Kerkstra, 1996). The deployment
of the necessary mix of professional knowledge and skills for the specific needs
of patients requires cooperation between professionals to ensure that their
efforts match recipients’ needs. The demand for better coordination in health
care refers not just to increased cooperation between sectors or levels of care but
also to the situation within primary care, which is considered to be too
fragmented.
Vignette 1.1 The Almere experiment1
In 1968, the first steps were taken on the newly reclaimed land of “Zuidelijk Flevoland”. In a part of this vast new polder, not far from Amsterdam, a
new town was planned. In 1978, the first inhabitants entered their houses.
Now, Almere has 165,000 inhabitants, with an average annual increase of
6500.
In the time that Almere was on the drawing boards, white papers were
published about the urgent need to strengthen the Dutch primary care
system to meet changing patient demand and to reduce the need for
secondary care. There was a lack of coherence and coordination between
specializations that led to fragmentation in primary care. At that time, GPs
were private entrepreneurs mainly working in solo practice. Although the
concept of integrated multidisciplinary health centres had been implemented in new housing estates, large-scale systemic change appeared to
be very difficult.
Almere became a challenge to design a well-developed coherent system
of primary care with a minimum amount of secondary level facilities.
Supported by the authorities, a group of young health care workers, in
collaboration with groups of active citizens, took the initiative in 1979 to
start the Almere health care experiment, with the objective of avoiding
the problems and shortcomings of the existing Dutch arrangements.
Instead of care provided by individual private practiotners, integrated
Coordination and integration in European primary care 11
health centres would have a variety of professionals working in collaboration for the benefit of the population within well-defined catchment
areas. Since the traditional combination of entrepreneur and caregiver
was seen to be potentially confusing, a foundation was created to employ
all GPs, physiotherapists, pharmacists, dentists, midwives and auxilliary
staff. Later, social workers and community nurses were also employed by
this foundation. GPs provided comprehensive services including first aid,
minor surgery, child health care and major parts of ophthalmology. The
goal was to reduce referrals to medical specialists. The use of antibiotics,
particularly by children, was to be reduced, as were tonsillectomies.
Furthermore, it was mandated that there would be at least one female GP
in every health centre, so that patients who so wished could choose a
female doctor.
From 1983 until 1992, the experiment had the legal status of a formal
project, with special funding and regulations intended to establish new
types of health care workers. One result of the Almere philosophy was that
a small hospital was not opened until 1991. In the course of those years
the use of hospital services was indeed lower. GPs and hospital specialists
developed an intensive collaboration in a structural working group. A
similar working relationship was established with a psychiatric centre that
opened in 1997. In 1999, the foundation for primary care in Almere (EVA)
merged with the organization running the nursing home and homes for
the elderly.
The experiment has been successful in many regards as it has created a
strong local network of health centres. Evaluation has shown that referral
rates were lower than the national average, particularly when the age
structure of the population was taken into account. Citizens of Almere are
satisfied with the services and more than elsewhere health centres are
involved in public health.
On the other hand, there have also been some setbacks. Most inhabitants of Almere previously lived in the old quarters of Amsterdam. They
brought with them a pattern of expectations and health care consumption that was not always in line with the ideals of their new GP. These
ideals may have suffered in the negotiation of this new healthcare strategy. The experiment also evolved in other respects as time went by. Those
who subsequently worked for the Almere experiment were less idealistic
and more pragmatic. They achieved an umbrella organization in Almere
with working conditions that were still hard to realize elsewhere in the
country.
There were three priorities that were central to the Almere experiment:
teamwork, working part-time and delegation of tasks. In the Netherlands
most professionals are not well prepared for teamwork because each profession fears losing their independence. In Almere, teamwork is the core of
primary care provision and for many health care workers this was a reason
to choose to work there. Newly attracted staff need to be trained for
the working arrangements in the health centres. There has been much
12 Primary care in the driver’s seat?
resistance in general practice concerning working part-time because it
was seen as a threat to the concepts of personal, integral and continuous
care. However, with the expanding proportion of female GPs in the
Netherlands, there was a growing need for part-time work. At an early
stage, these conflicting needs were reconciled in Almere. The result is that
now 50% of the GPs in Almere are female, whereas the national proportion is 28%. Task delegation has also been well developed in Almere. Substitution has been realized between secondary care and primary care, but
also within primary care. Some traditional GP tasks, for instance in care
for the chronically ill and elderly, are now being delegated to newly introduced nurse practitioners and other staff. In Almere these changes have
been implemented without fear of losing status in the health care market.
Recently, there have been additional innovations. GP service during
evenings, nights and weekends has been reorganized. There is a betterequipped and staffed central GP facility for out-of-hours services for the
city. Physiotherapy is becoming increasingly involved in guidance and
follow-up with patients at risk of heart disease, the overweight and those
with chronic diseases. Most physiotherapists have specialized in manual
therapy, child physiotherapy or sport injuries. The supply of social services work has been extended with the introduction of primary care
psychologists.
Almere is no longer an experiment, nor is it mainstream primary care in
the Netherlands. Due to its special structure and its special population of
health care workers, it is easier to implement changes, such that it will
continue to be a model within the Dutch health care system.
Continuity of care
Continuity is the degree to which a series of discrete health care events is experienced as coherent and connected, and is consistent with the patient’s medical
needs and personal context (Haggerty et al., 2003). Essential in this definition is
the personal perspective of the patient: continuity is what patients perceive.
Coordination and teamwork is what providers do for the benefit of continuity.
In primary care, continuity is usually seen as the continued relationship
between a patient and a particular provider – rather than a team – beyond
care episodes. This is also referred to as personal continuity (Hjortdahl and
Borchgrevink, 1991; Hjortdahl, 2004). However, the sense of affiliation between
patient and caregiver is stronger in general practice than in some other professions, such as nursing, where a consistent approach is emphasized by the
transfer of information. In addition to the personal perspective of a single
patient, the second key element of continuity is longitudinality (Schers, 2004).
The time frame may be relatively short, for instance an episode of care, or much
longer, such as a long-standing relationship between patient and GP. Depending
on the type of provider and the context of care, Haggerty et al. (2003) distinguish three types of continuity: informational, managerial and relational.
Coordination and integration in European primary care 13
Informational continuity is the use of information, either documented or in
the memory of providers, on past events and personal circumstances, to
make current care appropriate for the individual. Information links care from
one provider to another and from one event of care to another. Managerial
continuity is the consistent and coherent approach of several professions to the
management of health conditions (especially if chronic or complex) that is
responsive to a patient’s changing needs. Continuity is achieved if services are
delivered in a complementary and timely manner, for instance by means of
protocols. Relational continuity is the ongoing therapeutic relationship between
patient and provider(s). Continuity is a quality relevant to care at different
levels: in the relationship between patient and provider; among providers of
one discipline; between disciplines and between organizations, levels or sectors
of care. In the context of this book, informational continuity and managerial
continuity are most relevant.
Coordination, teamwork, integration
When more than one provider is involved in administering care to an individual patient, some form of coordination will be necessary to realize continuity. The degree of coordination needed in specific situations depends on the
complexity of the case and the options open to the patient. The conceptual
framework developed by Boon et al. (2004) has distinguished seven models of
care provision on the continuum between strict solo provision on the one hand
and full integration of disciplines for the provision of curative, rehabilitative
and preventive services on the other. In the non-coordination model, called
parallel practice, practitioners work independently and carry out a formally
defined set of services. In consultative practice, information concerning particular
patients is shared informally and on a case-by-case basis. In the coordinated
model, the communication and exchange of patient records is related to particular diseases or therapies and is based on a formal administrative structure; a
case coordinator monitors the transfer of information. More articulated, more
formalized and usually more numerous is the multidisciplinary team, led by a
team leader and possibly sub-teams and sub-team coordinators. When members
of a team start making group decisions or developing shared care policy, facilitated by regular face-to-face meetings, the multidisciplinary team has become
an interdisciplinary team. Finally, the model of integrative team care is reached if
the interdisciplinary team, based on a shared vision, provides ‘a seamless continuum of decision making and patient-centred care and support’ (Boon et al.,
2004).
A major reason why health care and primary care are still neither very coherent, nor very cost-effective, and why curative and preventive services are still
too separate, is that coordination and teamwork are difficult to achieve. The
success of new arrangements – such as shared care or several forms of substitution within primary care or between primary and secondary care – depends on
cooperation and teamwork. The extensive literature on multidisciplinary collaboration has described the obstacles that have to be overcome. In addition to
basic problems, related to differences in social status, employment, education,
14 Primary care in the driver’s seat?
power and gender (Mur-Veeman et al., 2001), there is little evidence on what the
optimum model of collaboration looks like and how effective teams should be
led. And even if teams work effectively it should not be assumed that it is automatically cheaper (Wolters et al., 2004). It may be concluded that improving the
collaboration and teamwork in primary care requires a multifaceted approach
from decision-makers, management and health care workers (Poulton and
West, 1993; West and Slater, 1996; Winkler, 2000). Health care systems in
Europe differ considerably as far as the degree to which this has been successful
is concerned (Boerma and Fleming, 1998). Not surprisingly, in countries with
strong primary care systems there has been relatively greater attention paid to
the development of collaboration and teamwork in primary care and to the
smoothening of the interface between primary care and secondary care (Van
Weel, 1994; Busby et al., 1999; Temmink et al., 2000; Iliffe et al., 2002; Brown et
al., 2003; Rummary and Colemen, 2003). These experiences may be useful to
further developing primary care in other countries.
Working definition
In the previous sections, primary care has been considered from several points
of view. This has clarified the type of care provided in extended primary care
and the disciplines potentially involved. We have seen why continuity is an
important requirement and how collaboration, teamwork and other methods of
coordination can promote the continuity of care for different categories of
patients. Our working definition summarizes the features of extended primary
care that are important in the context of this book. Primary care:
• refers to directly accessible, first contact ambulatory care for unselected health
(related) problems;
• offers diagnostic, curative, rehabilitative and palliative services in response to
the bulk of these problems;
• offers prevention to individuals and groups at risk in the population served;
• takes into account the personal and social context of patients;
• is provided by a variety of disciplines, either within primary care, secondary
care or related sectors;
• assures patients continuity of care over time as well as between providers.
This definition can serve as a yardstick in the examination of primary care systems across Europe. The wide diversity in primary care in European countries, as
discussed below, points to different conditions for the provision of primary care.
For instance, continuity of care is not readily achievable if the organization of
primary care is small scale and fragmented, or if there is no single point of entry
to the health care system. Structural characteristics of health care, such as the
mode of financing, determine possibilities for the provision of primary care.
Financing arrangements influence not only how and where patients enter
health care, but also the opportunity to establish a longer term relationship
between patient and primary care provider, for providers to keep patient records
routinely, to maintain adequate professional education and quality of care, or to
foster cooperation between providers at different levels. How such conditions
Coordination and integration in European primary care 15
emerge and what strategies are effective to support primary care in particular
countries depends on the prevailing national governance and health care
structure.
Potential of primary care
There is considerable agreement, especially among international organizations
and academics, that a strong primary care system is the linchpin of effective
health care delivery and that it can help resolve the lack of continuity and
responsiveness in health care in general (Saltman and Figueras, 1997; WHO,
2002). There is indeed considerable logic in thinking that the entrance point to
the system is the obvious place where improved coordination should take place.
Although there are critics who question the evidence for these arguments
(Maynard and Bloor, 1995; Sheaff, 1998), studies have suggested that strong
primary care based systems are cheaper to operate than more “open” systems
and that their health outcomes are better (Starfield, 1994; Doescher et al., 1999;
Shi et al., 2002; Macinko et al., 2003). One study conducted in OECD countries
found that systems with gatekeeping GPs were better able to control the costs of
ambulatory care (Delnoij et al., 2000). It therefore could be concluded provisionally in the European context that primary care-based systems are more
cost effective. At meso and micro level there have been many studies on the
effectiveness of collaborative, team and “shared” approaches to care, either
within primary care or involving various levels of care, showing that these can
promote continuity of care and be effective in dealing with new tasks (although
they are not necessarily cheaper) (Poulton and West, 1993; Vierhout et al., 1995;
Calnan et al., 1996; Shum et al., 2000; Temmink et al., 2000; Renders et al., 2001;
Brown et al., 2003; Faulkner et al., 2003; Murchie et al., 2003; Oakeshott et al.,
2003; Vlek et al., 2003; Campbell, 2004; Rat et al., 2004; Wolters et al., 2004).
There is no direct evidence available about continuity of care, although greater
cost-effectiveness may have resulted from better cooperation and coordination
mechanisms.
Reservations
The positive expectations among policy-makers for a more central coordinating
role of the primary level of health care, however, are in contrast to the diversity
of opinions about the organizational mechanisms best suited to achieve that
aim. This is due to the fact that health care functions are similar in any country,
but the organizational system and the providers involved are quite diverse.
This reflects the European reality, with quite different situations of primary care,
as explained below. At present some health care systems are already formally
based on primary care, including a referral system to secondary care and gatekeeping general practitioners (GPs) with broad task profiles, while others are
based more on specialist services with a less exclusive domain for GPs (Boerma
and Fleming, 1998). Other differences that create incomparable conditions
relate to the financing structure, the mode of governance and the role of
16
Primary care in the driver’s seat?
professional organizations. A more centralized NHS system, like in the UK,
offers quite different conditions for policy-making and coordination than a
social security environment, for example in Germany or France, where more
parties are involved in decision-making (Saltman et al., 2004).
Another issue, however should, probably precede questions about whether
primary care could be installed in the driver’s seat, how that could be realized,
and whether it is desirable to do so. The delegation of coordination powers to
providers in primary care, for instance GPs, may entail a dual role as both
coordinators and providers of care. This may create a conflict of purpose (also
discussed in Chapter Four). The important question is whether primary care has
the capacity to handle new, complex tasks without losing hold of its main
responsibility as the provider of care. First and foremost, GPs are the agents of
their patients with professional values that require investing as high a level of
resources as possible in those patients. However, to become efficient coordinators, they must incorporate “higher level concerns”, and may therefore find
themselves divided between these different responsibilities. Vice versa, one
may even wonder about the influence of “coordinating doctors” on their
professional values. A good division of tasks within primary care teams could
potentially offer a solution to this conflict.
And what about the decision-makers: are they in favour of strengthening
primary care? In their analysis of reforms in primary care systems in OECD
countries, Macinko et al. (2003) found that only a few countries have been able
to improve essential features of primary care since 1970. Does that reflect the
stubbornness of health care reform or the absence of reasons for profound
changes? Policy-makers, professionals and the public in countries where primary care is not well developed may not feel strongly attracted to the idea. They
may come to see primary care as useful for cost containment, yet generally
consider it a lower grade service compared to specialist care. In Central and
Eastern Europe, countries had little choice but to change fundamentally their
health care systems. Their experiences have taught us about the impact of
radical reforms and the time it takes before the reformed system finds stability
again.
Different possibilities
For most countries in Europe, the conclusion that neither extended primary
care nor general practice specifically serve as the firm basis of health care is
justified. Instead, primary care and GPs offer a heterogeneous set of services,
often in competition with specialist services (Boerma and Fleming, 1998). In
countries where it is hard to identify clear boundaries between levels of care,
coordination and continuity of care is difficult to achieve, and possibilities for a
steering role of primary care are obviously limited. But even in countries where
citizens are on the list of a gatekeeping GP, primary care is usually not the most
powerful echelon of health care. This creates a paradoxical situation: the tension between the relative weakness and unattractiveness of this level of care
versus the intention to assign critical strategic functions to it. This primary care
paradox is a basic concern that runs throughout this volume. Available strategies
Coordination and integration in European primary care 17
need to be considered that could tip the balance of the health care system
towards primary care.
The three chapters that follow in Part One seek to provide a range of perspectives on the context for this central paradox. Chapter Two maps out the existing
distribution of key primary care resources across Europe and examines in close
detail the type and form of activities in which primary care personnel engage.
Chapter Three analyses the process of governance in primary care, detaching
the ways in which it has evolved and providing a framework for thinking about
how it might develop in the future. Lastly, Chapter Four draws together the
central themes that tie the volume together, exploring in particular the major
challenges that primary care currently faces.
In Part Two, the chapters utilize both conceptual theories as well as national
experience to probe more deeply into a number of key aspects of primary care
raised in Part One. Chapters Five, Six, and Seven explore the changing institutional arrangements in European primary care, assessing the issues of coordination, purchasing, and the public-private mix. Chapters Eight, Nine, and Ten
review changing work arrangements, including task profiles, training, and
financial incentives. Finally, Chapters Eleven and Twelve examine changing
quality standards, assessing efforts to emprove quality of care as well as to introduce new information and communication technologies. Taken together, the
eight chapters in Part two are intended to provide the detailed case-based depth
that can help amplify and reinforce the conceptual perspective and analysis
presented in the four chapters of Part One.
Note
1
This vignette was written by Bert Groot Roessink, GP and Director, Curative Care,
Almere, the Netherlands.
References
Abel-Smith, B. (1992). Cost containment and the new priorities in the European Communities, The Milbank Quarterly 70(3): 417–416.
Abel-Smith, B. and Mossialos, E. (1994). Cost containment and health care reform: a study
of the European Union, Health Policy 28(2): 89–132.
Boerma, W.G.W. (2003). Profiles of general practice in Europe. An international study of
variation in the tasks of general practitioners. Utrecht: NIVEL (dissertation).
Boerma, W.G.W. and Fleming, D.M. (1998). The role of general practice in primary health care.
Norwich: WHO Europe/The Stationery Office.
Boerma, W.G.W., De Jong, F. and Mulder, P. (1993). Health care and general practice across
Europe. Utrecht: NIVEL.
Boerma, W.G.W., Groenewegen, P.P. and Van der Zee, J. (1998). General practice in
urban and rural Europe; the range of curative services, Social Science and Medicine 47:
445–453.
Boerma, W.G.W., Van der Zee, J. and Fleming, D.M. (1997). Service profiles of general
practitioners in Europe, British Journal of General Practice 47: 481–486.
Boon, H., Verhoef, M., O’Hara, D. and Findlay, B. (2004). From parallel practice to integrative health care: a conceptual framework, BMC Health Services Research 4: 15.
18 Primary care in the driver’s seat?
Bower, P. and Sibbald, B. (2004). The health care team, in R. Jones, N. Britten, L. Culpepper
et al. (eds). Oxford Textbook of Primary Medical Care. Volume 1. Oxford: Oxford
University Press.
Braspenning, J.C.C., Schellevis, F.G. and Grol, R.P.T.M. (2004). Tweede Nationale Studie naar
ziekten en verrichtingen in de huisartspraktijk: kwaliteit huisartsenzorg belicht. Utrecht/
Nijmegen: NIVEL/Centre for Quality of Care Research (WOK).
Brown, L., Tucker, C. and Domokos, T. (2003). Evaluating the impact of integrated health
and social care teams on older people living in the community, Health and Social Care
in the Community 11(2): 85–94.
Busby, H., Elliott, H., Popay, J. and Williams, G. (1999). Public health and primary care: a
necessary relationship, Health and Social Care in the Community 7(4): 239–241.
Calnan, M., Canr, S., Williams, S. and Killoran, A. (1996). Involvement of the primary
care team in coronary heart disease prevention, British Journal of General Practice 46:
465–468.
Calnan, M., Cant, S., Williams, S. and Killoran, A. (1994). Involvement of the primary
health care team in coronary heart disease prevention, British Journal of General
Practice 44(382): 224–228.
Campbell, N.C. (2004). Secondary prevention clinics: improving quality of life and
outcome, Heart 90 (supplement 4): 29–32.
Delnoij, D.M.J., Van Merode, G., Paulus, A. and Groenewegen, P.P. (2000). Does general
practitioner gatekeeping curb health care expenditure? Journal of Health Services
Research and Policy 5: 22–26.
Doescher, M.P., Franks, P. and Saver, B.G. (1999). Is family medicine associated with
reduced health care expenditures? Journal of Family Practice 49: 608–614.
Donaldson, J.S., Yordy, K.D., Lohr, K.N. and Vanselow, N.A. (eds) (1996). Primary Care:
America’s Health in a New Era. Institute of Medicine, Division of Health Care Services,
Committee on the Future of Primary Care. Washington DC: National Academy Press.
Faulkner, A., Mills, N., Bainton, D. et al. (2003). A systematic review of the effect of primary care-based service innovations on quality and patterns of referral to specialist
secondary care, British Journal of General Practice 53: 496, 878–884.
Fry, J. (1972). Considerations of the present state and future trends of primary, personal,
family, and general medical care, International Journal of Health Services 2(2): 159–324.
Gervas, J., Perez Fernandez, M., and Starfield, B. (1994). Primary care, financing and
gatekeeping in Western Europe, Family Practice 11: 307–317.
Haggerty, J.L., Reid, R.J., Freeman, G.K., Starfield, B.H. and Adair, C.E. (2003). Continuity
of care: a multidisciplinary review, British Medical Journal 327: 1219–1221.
Hjortdahl, P. (2004). Continuity of care, In: R. Jones, N. Britten, L. Culpepper et al. (eds).
Oxford Textbook of Primary Medical Care. Volume 1. Oxford: Oxford University Press.
Hjortdahl, P. and Borchgrevink, C.F. (1991). Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations, British
Medical Journal 303: 1181–1184.
Hughes, C.M. and McCann, S. (2003). Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment, British Journal
of General Practice 53(493): 600–607.
Hutten, J.B.F. and Kerkstra, A. (1996). Home Care in Europe. A Country Specific Guide to its
Organisation and Financing. Aldershot: Arena Ashgate Publishing Ltd.
Iliffe, S., Lenihan, P., Wallace, P., Drennan, V., Blanchard, M. and Harris, A. (2002). Applying community-oriented primary care methods in British general practice: a case
study, British Journal of General Practice 52: 646–651.
Isles, C.G., Ritchie, L.D., Murchie, P. and Norrie, J. (2000). Risk assessment in primary
prevention of coronary heart disease: randomised comparison of three scoring
methods, British Medical Journal 320: 690–691.
Coordination and integration in European primary care 19
Kinnersley, P., Andersen, E., Parry, K. et al. (2000). Randomised controlled trial of nurse
practitioner versus general practitioners care for patients requesting “same day”
consultations in primary care, British Medical Journal 320(7241): 1043–1048.
Koster, M.K., Dekker, J. and Groenewegen, P.P. (1991). The position and education of some
paramedical professions in the United Kingdom, The Netherlands, The Federal Republic of
Germany and Belgium. Utrecht: NIVEL.
Leeuwenhorst Group (1974). The General Practitioner in Europe. A Statement by the Working
Party appointed by the Second European Conference on the Teaching of General Practice.
Dublin: Leeuwenhorst Group.
Macinko, J., Starfield, B. and Shi, L. (2003). The contribution of primary care systems to
health outcomes within Organization for Economic Cooperation and Development
(OECD) countries, 1970–1998, Health Services Research 38(3): 831–865.
Maynard, A. and Bloor K. (1995). Help or hindrance? The role of economics in the rationing of health care, British Medical Bulletin 51(4): 854–868.
McKee, M. and Healy, J. (eds) (1992). Hospitals in a Changing Europe. Buckingham: Open
University Press.
Menotti, A., Mulder, I., Nissinen, A., Giampaoli, S., Feskens, E.J. and Kromhout, D. (2001).
Prevalence of morbidity and multimorbidity in elderly male populations and their
impact on 10-year all-cause mortality: The FINE study (Finland, Italy, Netherlands,
Elderly), Journal of Clinical Epidemiology 54(7): 680–686.
Ministerie van Volksgezondheid en Milieuhygiëne [Dutch Ministry of Health and
Environmental Hygiene] (1974). Structuurnota Gezondheidszorg [Policy note on health
care]. Leidschendam: Ministerie van Volksgezondheid en Milieuhygiëne.
Ministerie van Volksgezondheid en Milieuhygiëne [Dutch Ministry of Health and
Environmental Hygiene] (1980). Schets van de Eerstelijnsgezondheidszorg [Primary care
draft]. Leidschendam: Ministerie van Volksgezondheid en Milieuhygiëne.
Muijrers, P.E., Knottnerus, J.A., Sijbrandij, J., Janknegt, R. and Grol, R.P. (2004). Pharmacists
in primary care. Determinants of the care-providing function of Dutch community
pharmacists in primary care, Pharmacy World and Science 26(5): 256–262.
Murchie, P., Campbell, N.C., Ritchie, L.D., Simpson, J.A. and Thain, J. (2003). Secondary
prevention clinics for coronary heart disease: four year follow-up of a randomised
controlled trial in primary care, British Medical Journal 326: 84–90.
Mur-Veeman, I., Eijkelberg, I. and Spreeuwenberg, C. (2001). How to manage the implementation of shared care: a discussion of the role of power, culture and structure in
the development of shared care arrangements, Journal of Management in Medicine
15(2): 142–155.
Oakeshott, P., Kerry, S., Austin, A. and Cappuccio, F. (2003). Is there a role for nurse-led
blood pressure management in primary care? Family Practice 20(4): 469–473.
OECD (1995). New Directions in Health Care Policy. Paris: OECD.
Olesen, F. (2002). Do we need a definition of general practice/family medicine? European
Journal of General Practice 8: 138–139.
Page, L. (2001). Human resources for maternity care: the present system in Brazil, Japan,
North America, Western Europe and New Zealand, International Journal of Gynecology
and Obstetrics 75 (suppl.1): 81–88.
Paton, C. (2000). Scientific Evaluation of the Effects of the Introduction of Market Forces into
Health Systems. A Review of Evidence in the 15 European Union Member States. Dublin:
European Health Management Association.
Poulton, B.C. and West, M.A. (1993). Effective multidisciplinary teamwork in primary
health care, Journal of Advanced Nursing 18: 918–925.
Pringle, M. and Irvine, S. (2004). Practice structures, in R. Jones, N. Britten, L. Culpepper
et al. (eds) Oxford Textbook of Primary Medical Care. Volume 1. Oxford: Oxford
University Press.
20 Primary care in the driver’s seat?
Raad voor de Volksgezondheid en Zorg (2004). European Primary Care. The Hague: Raad
voor de Volksgezondheid en Zorg.
Rat, A.C., Henegariu, V. and Boissier, M.C. (2004). Do primary care physicians have a place
in the management of rheumatoid arthritis? Joint Bone Spine 71(3): 190–197.
RCGP (1972). The Future GP: Learning and Teaching. London: Royal College of General
Practitioners (RCGP)/BMJ Publications.
Renders, C.M., Valk, G.D., Griffin, S., Wagner, E.H., Eijk, J.T. and Assendelft, W.J. (2001).
Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings, Cochrane Database Systematic Review 1, CD001481.
Rummery, K. and Coleman, A. (2003). Primary health and social care services in the UK:
progress towards partnership? Social Science and Medicine 56: 1773–1782.
Saltman, R.B. and Figueras, J. (1997). European Health Care Reform: Analysis of Current
Strategies. Copenhagen: WHO Regional Office for Europe.
Saltman, R.B., Busse, R. and Figueras, J. (eds) (2004). Social Health Insurance Systems in
Western Europe. Berkshire/New York: Open University Press/McGraw-Hill Education.
Schers, H.J. (2004). Continuity of Care in General Practice. Exploring the Balance between
Personal and Informational Continuity. Nijmegen: Radboud University Nijmegen
(dissertation).
Sheaff, R. (1998). What is “primary” about primary health care? Health care Analysis 6:
330–340.
Shi, L., Starfield, B., Politzer, R. and Regan, J. (2002). Primary care, self-rated health, and
reductions in social disparities in health, Health Services Research 37(3): 529–550.
Shum, C., Humphreys, A., Wheeler, D., Cochrane, M.A., Skoda, S. and Clement, S. (2000).
Nurse management of patients with minor illnesses in general practice: multicentre,
randomised controlled trial, British Medical Journal 320: 1038–1043.
Silcock, J., Rayner, D.K.T. and Petty, D. (2004). The organisation and development of
primary care pharmacy in the United Kingdom, Health Policy 67: 207–214.
Starfield, B. (1991). Primary care and health. A cross-national comparison, Journal of the
American Medical Association 266(16): 2268–2271.
Starfield, B. (1992). Primary Care, Concept, Evaluation and Policy. New York/Oxford: Oxford
University Press.
Starfield, B. (1994). Is primary care essential? The Lancet 344: 1129–1133.
Starfield, B. (1998). Primary Care. Balancing Health Needs, Services, and Technology. New
York/Oxford: Oxford University Press.
Starfield, B. and Shi, L. (2002). Policy relevant determinants of health: an international
perspective, Health Policy 60(3): 201–18.
Temmink, D., Francke, A.L., Hutten, J.B., Van der Zee, J. and Huijer Abu-Saad, H. (2000).
Innovations in the nursing care of the chronically ill: a literature review from an
international perspective, Journal of Advanced Nursing 31(6): 1449–1458.
Van den Akker, M., Buntinx, F., Metsemakers, J.F., Roos, S. and Knottnerus, J.A. (1998).
Multimorbidity in general practice: prevalence, incidence and determinants of
co-occurring chronic and recurrent diseases, Journal of Clinical Epidemiology 51(5):
367–375.
Van der Zee, J. (1989). Over de grenzen van de eerste lijn; vergelijkend onderzoek in een Europese
regio [Over the borders of primary care. Comparative study in a European Region]. Inaugural
lecture. Utrecht/Maastricht: NIVEL/Rijksuniversiteit Limburg.
Van der Zee, J., Boerma, W.G.W. and Kroneman, M.W. (2004). Health care systems: understanding the stages of development, in R. Jones, N. Britten, L. Culpepper et al. (eds).
Oxford Textbook of Primary Medical Care. Volume 1. Oxford: Oxford University Press.
Van Weel, C. (1994). Teamwork, Lancet 344: 1276–1279.
Van Weel, C. (1999). International research and the discipline of family medicine, European
Journal of General Practice 5: 110–115.
Coordination and integration in European primary care 21
Vierhout, W.P., Knottnerus, J.A., Van Ooij, A. et al. (1995). Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor system
disorders, Lancet 346(8981): 990–994.
Vlek, J.F., Vierhout, W.P., Knottnerus, J.A. et al. (2003). A randomised controlled trial of
joint consultations with general practitioners and cardiologists in primary care,
British Journal of General Practice 53(487): 108–112.
Vrijhoef, H.J.M. (2002). Is It Justifiable to Treat Chronic Patients by Nurse Specialists? Evaluation
of Effects on Quality of Care. Maastricht: Universitaire Pers Maastricht.
West, M. and Slater, J. (1996). Teamworking in Primary Health Care: A Review of Its Effectiveness. London: Health Education Authority.
Westert, G.P., Satariano, W.A., Schellevis, F.G. and Van den Bos, G.A. (2001). Patterns of
comorbidity and the use of health services in the Dutch population, European Journal
of Public Health 11(4): 365–372.
WHO (1978). Declaration of Alma-Ata. International Conference on Primary Health
Care: Alma-Ata, 6–12 September 1978 (http://www.who.int/hpr/NPH/docs/
declaration_almaata.pdf, accessed 18 February 2005).
WHO (2002). The European Health Report 2002. Copenhagen: WHO Regional Office for
Europe.
Wiegers, T.A., Van der Zee, J. and Keirse M.J. (1998). Maternity care in The Netherlands:
the changing home birth rate, Birth 25(3): 190–197.
Winkler, F. (2000). Multidisciplinary Collaboration in Primary Care. Paper presented at
4th meeting of St Petersburg Initiative. Minsk: World Health Organization.
Wolters, R., Wensing, M., Klomp, M. and Grol, R. (2004). Shared care and the management of lower urinary tract symptoms, BJU International 94(9): 1287–1290.
WONCA (1991). The role of the general practitioner/family physician in health care systems;
A statement of the World Organization of National Colleges, Academies and Academic
Associations of General Practitioners/Family Physicians. Victoria: WONCA.
WONCA (2002). The European Definition of General Practice/Family Medicine. Singapore:
World Organization of Family Doctors (WONCA).
chapter
two
Mapping primary care
across Europe
Wienke G.W. Boerma and
Carl-Ardy Dubois
Although growing integration has reduced differences between European countries in a variety of economic sectors, the organization and provision of health
care continues to be relatively diverse (Belien, 1996; Goicoechea, 1996; Helman,
1998). Reflecting this diversity as well as the practicality that health care is
still mainly a national affair in the European Union, there is little comparable
data available on organization and provision. The lack of information and
evidence is particularly noticeable given the broad range of health care reforms
that have occurred since the early 1990s, many of which have affected primary
care. Examples of such reforms are the introduction of GP fundholding and the
later Primary Care Groups and Trusts in the United Kingdom, family doctor
systems in Sweden (later largely dropped) and Finland, and policies in Germany,
France, Norway and Finland leading to voluntary patient list systems and a
stronger coordinating role for GPs (Alban and Christiansen, 1995; Niemelä,
1996; Vehvilaeinen et al., 1996; Le Grand et al., 1998; Aguzzoli et al., 1999;
Bundesministerium für Frauen, Jugend und Gesundheit, 2000).
Vignette 2.1 Finnish primary health centre1
Janakkala is a middle-income town of 15,000 about 150 km north of
Helsinki. Its main industry is a large forest products mill, thus it has a
relatively large number of industrial workers as residents. In size, population distribution, and income, it is very close to the median for all Finnish
municipalities. The primary health centre employs its full complement of
10 GPs, as well as a substantial number of nurses and aids. It also has on
staff a social worker and several health education personnel. Facilities
Mapping primary care across Europe
include clinic rooms and its own X-ray and laboratory facility. Like most
primary health centres in Finland, it also has several wards of inpatient
beds – referred to in Finland as a ‘primary care hospital’. These 85 beds, in
Janakkala’s case, provide long-term skilled nursing care for elderly
patients who are unable to remain at home but are not sick enough to
warrant inpatient hospital treatment. The beds are oversubscribed, and
the health centre recently added nine beds in order to reduce the number
of elderly who had to be sent to the district hospital for care.
The health centre is owned and operated by Janakkala municipality.
The elected municipal council makes general policy for all municipal
services, while an appointed Health and Social Board, composed of several
elected members of the council, the chief doctor in the primary care
centre, and a municipal administrator responsible for health and social
care, is responsible for supervising the municipality’s health and social
care activities. The board is also responsible for arranging inpatient
hospital services for Janakkala’s residents through a well-developed
contracting process (see below).
Over the past 10 years, the municipality has gained considerable financial and managerial freedom in how it manages its health sector responsibilities. Previously, a wide variety of state controls over funding (the state
provided a sliding subsidy to Finnish municipalities of 39–61 % of total
health expenditures) and staff salary levels, a state-mandated municipal
obligation to hold capital shares in the district and specialist hospital (and
thus to send Janakkala’s patients only to those institutions), and a near
complete inability on the part of the municipality to influence either
the hospital’s overall budget or the portion to be paid by Janakkala, all
had resulted in a sense within Finnish municipalities that, although
they formally owned both their primary health centres and the hospitals,
in practice they had little effective say in what they did or what it cost.
By 2002, all of these restraints on municipal decision-making had
been removed. For example, Janakkala decided in summer 2001 to
solve its continuing problem of inadequate coverage for GPs. By decision
of the municipal council, it raised the salary paid to GPs to well above
the minimum required by the national union contract, enabling it to
attract a full compliment of 10. Since it now had full control over how it
spent its funds and also the salary range paid to staff, this solution became
possible.
Janakkala municipality has signed four separate contracts for specific
medical services to supplement those provided by its own primary health
centre. They were for:
•
•
•
•
specialist hospital services;
visiting specialist clinics organized in Janakkala’s primary health
centre;
endoscopic services in the primary health centre;
out-of-hours emergency coverage.
23
24
Primary care in the driver’s seat?
While the second, third and fourth contracts are relatively straightforward
efforts to supplement on-site clinical services with outside providers; the
first contract is quite complex. It is a public contract, agreed between two
publicly owned and operated entities (the municipality and the hospital
district). There is no state supervision or approval in Finland of either the
contract terms or the contract process – a legacy of the municipalities’
‘Spring Revolt’ in 1987 that resulted in the state granting nearly full
operating control over health care to municipal governments.
The hospital contract is based on the past two and a half years’ experience of inpatient use by Janakkala patients in the nearby public specialist
hospital (of which Janakkala is still technically an owner and for which it
sits on the Hospital District Board). For each fiscal year (same as the calendar year), the hospital makes a “proposal” to the municipality. The municipality then responds, and the two ultimately agree on a final amount.
For fiscal year 2003, the agreed figure is 5.2% higher than for fiscal year
2002 (not inflation adjusted). It is a fixed price contract: the municipality
will receive nothing back if volume or costs are lower than expected, while
the hospital receives nothing more if volume or costs are higher than
expected. The contract does contain a clause, however, that if during the
contract period the current level of municipally provided services in
primary or social care should materially change – for whatever reason, and
whether to be more or less comprehensive or extensive – then the contract
amount will be opened up for reconsideration. The only aspect of the
current contract that concerns Janakkala’s health and social care administration is that the contract has no quality of care specifications – although
to date there has been no adverse consequences for Janakkala’s patients, as
the quality of care at the specialist hospital is considered to be quite good
as compared with all Finnish hospitals.
Two additional aspects of the Janakkala primary care centre are worth
noting. First, although Janakkala had considered sending their laboratory
work to the specialist hospital and closing their own facility, they decided
against it for both financial (few substantial savings) and patient convenience issues (patients would have to travel to the hospital for certain tests).
Second, Janakkala had decided to terminate its own in-house pharmacy
service, opting instead to have its drugs prepared by the (much bigger)
specialist hospital pharmacy and then sent out to the primary care centre
and hospital.
Both the chairwoman of Janakkala’s health and social board as well as
the municipal administrator for health and social care felt that the
municipality’s health services were working rather well. They were
pleased with their progress in the last several years, including the fact
that all 10 GPs saw patients for approximately 80% of their working
time (a relatively high ratio for a publicly operated health centre). They
were not content, however, with the fact that patients still had to wait
for up to two weeks for a regular (non-urgent) appointment with their
regular GP, since they could jump to the private sector and see a GP
Mapping primary care across Europe
25
within one-two days. Janakkala’s administrator also would like to have
quality of care parameters included in the contract with the specialist
hospital.
The context of funding and politics
Taxonomies of health care systems often take an approach based on the funding
mechanism, with countries divided into tax-based and social insurance systems.
Although the method of funding is an important factor in shaping the system, it
alone is insufficient to explain the diversity in health care delivery. For this
reason, we take an additional dimension into account, namely, the political
context.
The economic dimension in health systems encompasses both funding (including the collection and pooling) and the purchasing and provision of services
(Dixon et al., 2004). Functions that relate to primary care include the process
of mobilizing and distributing resources for primary care, the methods of
remuneration of primary care providers, the methods of organizing provision of
primary care services and the types of primary care services that are provided.
At the beginning of the 1990s, health care systems in Europe could be divided
into three broad models: the social health insurance model (“Bismarck
systems”), tax funded models (“Beveridge systems”), and the Soviet model
(“Semashko system”). However, no European health care system is an exact
replica of any specific model. Rather, each country has its own variation, in
which the basic model is adjusted to national particularities (Marrée and
Groenewegen, 1997). Furthermore, health care financing is not static. The institutional arrangements in the Beveridge and Bismarck countries have been subject to considerable experimentation intending to promote choice, encourage
competition, increase resources for health care, enhance responsiveness to
consumers’ wishes, expand coverage or counteract high labour market costs
(Saltman and Von Otter, 1992; Dixon and Mossialos, 2001). At the same
time countries in central and eastern Europe as well as a number of former
Soviet Republics are abandoning the Semashko model, most of them implementing insurance-based models and decentralized governance. Reforms
include the creation of independent practitioners, new methods of funding,
combining elements of capitation payment with incentives to undertake certain
activities, programmes of training and professional development, and mechanisms to provide capital funding to upgrade facilities and equipment (Preker
et al., 2002).
The political dimension includes both the balance of power between actors
involved in health care delivery and territorial administrative structures. Differences between health care systems do not lie in the types of actor, but in the way
these relationships are configured. The categories include patients or consumers
of services, providers of services (those directly contacted by patients and those
available via first level providers), funders or insurers of health care, and central
governments and regional authorities (Evans, 1981; OECD, 1992). The interaction between the actors relates to the provision of services to patients, referrals
26 Primary care in the driver’s seat?
Vignette 2.2 Family medicine in Romania2
Historical overview
During the communist period, health care in Romania was hospital
centred. Family doctors existed, but they worked in dispensaries that
reported to hospital directors and did not have an autonomous professional identity. This was the result of a medical education system which
was exclusively hospital oriented, without any attention to the morbidity
pattern that family doctors deal with. The fact that family doctors were
subordinated to the hospitals resulted in lower quality premises and
equipment that severely limited their diagnostic and therapeutic possibilities. All doctors were state employees and as such badly underpaid As a
result patients often had to pay ‘under the table’. Home care by nurses and
home helpers was virtually unknown, therefore bedridden patients were
forced to be hospitalized.
Until the mid–1990s, different family doctors treated different members
of one family, since there were separate family doctors for children, for
adults, for industrial workers, for soldiers and for railway personnel. This
system changed in 1995, but still today former paediatricians may prefer
to have children on their lists instead of adults. Often mothers are the
patients of a former adult doctor, while the child is on the list of a former
paediatrician.
There are also large differences in the content and workload of family
practice in towns and in rural regions. Because the distance to hospitals in
villages can be great, the rural population expects family doctors to provide a greater range of medical services than those living near hospitals. As
a result, rural family doctors have more opportunities to develop adequate
family medicine skills than their urban colleagues.
The current situation
After the 1989 revolution, a group of progressive family doctors established the Societatea Nationala de Medicina Generala (SNMG). They organized continuing education, produced two medical journals and they
sought to represent family doctors at the national level. Three years of
postgraduate training for family doctors was established, including one
year in a kind of teaching practicum. A small minority of family doctors
completed this programme.
State funding for the health care system was replaced in 1998 by a
health insurance system, which meant that the Ministry of Health no
longer dominated the health care system. This task was taken over by
Health Insurance Offices established in each district and also a National
Health Insurance Agency for the whole country. These new organizations
became responsible for both the structuring and financing of regional
health care. Paying premiums was a big change for the population.
Mapping primary care across Europe
27
Another change was the requirement that all inhabitants choose a family
doctor.
The changed structure of health care has been beneficial to Romania as a
pre-accession country of the EU, since a well-functioning primary care
system is one of the conditions of membership. Recently however, the
National Health Insurance Agency has come under the influence of the
Ministry of Health again and there is a widespread belief that the government is diverting health care resources that have been paid by employees
and employers to cover other debts.
Family doctors continued to be plagued by financial issues. On the one
hand, earnings have improved and they now receive a fee, partly per
capita and partly for service, which has created a better relationship
between workload and income. However, the problem remains that fees
are paid in “credit points”, the value of which is variable, set retrospectively, and subject to devaluation.
Family doctors have also become responsible for their own offices, this
too was formerly the responsibility of the hospital director. Family doctors
now receive a budget for their premises, equipment, heating and electricity and nurses’ salaries. This is a considerable step forward but the
budget often does not cover the real costs. In addition, many offices are in
poor condition and family doctors cannot invest in improvements
because the offices are part of a ‘commodity system’, which means for five
years the doctors cannot buy the premises. Overall, the income of family
doctors has improved compared to the previous situation (now about
$150 per month on an average), but most doctors still have financial problems. Negotiations with the Health Insurance offices are conducted by the
College of Physicians, in which medical specialists are the great majority,
and the Society of Family Doctors has only a consultative role.
Theoretically, the new health care structure constitutes a significant
improvement and makes family medicine the gatekeeper for health
services. In practice, however, this goal is not supported by the Ministry of
Health, which is still strongly influenced by specialists who view family
doctors as competitors.
from first level to second level providers, patients’ payment of insurance premiums (or taxes), payments for services and regulation by government. In
western Europe, a number of reforms have included initiatives aiming to bestow
greater power on intermediate or local tiers of governance. In central and
eastern Europe, health care policy-making is gradually shifting towards a less
hierarchical and more decentralized organization of health services. Notwithstanding this trend, the political organization of health care at subnational
levels in European countries follows diverse pathways and gives rise to a mosaic
of institutions, many rooted in historical, cultural and religious traditions
(Blanpain, 1994; Chinitz et al., 2004).
28
Primary care in the driver’s seat?
Resources for primary care
A number of health sector reforms during the 1990s have sought to readjust
the division of tasks between primary and secondary care. The role of primary
care in managing the entrance to and exit from secondary care has tended
to increase. In addition, inpatient care is required for a diminishing proportion
of those who enter the health care system and stays in hospitals have become
shorter (White et al., 1961; McKee and Healy, 2001). Many more patients can
be treated in the primary care setting, so that these services can account
for up to 90% of all health care activity (Hobbs, 1995). This figure highlights the need to achieve an appropriate balance of resources between primary
and secondary care, with adequate financial and human resources being
directed towards the primary care sector, and in line with changes in the task
division between primary and secondary care (Forrest and Starfield, 1996;
Jepson, 2001).
Availability of data
Information on the allocation of resources in health care is not plentiful. More
studies have focused on the hospital sector than on primary care, perhaps in
part because definitional problems related to primary care make comparison
difficult. As a consequence there is no source of comparable data on, for
example, the financial resources allocated to the primary care sector in Europe.
Neither the OECD database nor the Health-for-All database do not provide these
data. Some national databases give information on resources allocated to
primary care but differences in definitions, parameters, and data retrieval make
comparison difficult (Lagasse et al., 2001). With regard to human resources, data
on primary care practitioners are also incomplete and not always adequate.
Despite of the central role of human resources in the health sector, international
attention to human resources for health has only recently emerged on the
health policy agenda (Dubois et al., 2005 forthcoming).
Financial resources
Existing data on expenditure in primary care suggest that less than a quarter of
the health care budget generally goes to primary care in western Europe (Hobbs,
1995; Goicoechea, 1996; OHE, 2000). Overall, health care resources across
Europe have increased in real terms over recent decades, reflected in increases in
health expenditures. Indirect indicators, however, do not indicate that the proportion for primary care has increased drastically over time. In central and eastern Europe, where concerted attempts are being made to develop primary care,
data from the European Health For All database indicate that to date only Latvia
and Hungary have significantly reduced the proportion of the health budget
devoted to inpatient care. In other countries such as the former Yugoslav Republic of Macedonia and Slovenia, the fraction of health resources allocated to
inpatient care has continued to increase (WHO, 2004). Data from western European countries suggests a modest trend towards reducing or containing the
share of inpatient expenditure in total health expenditure (WHO, 2004). This is
Mapping primary care across Europe
29
consistent with significant decreases in hospital capacity and efforts to contain
hospital costs. At the same time, however, changes in skill mix and technological developments have enabled substitution of primary care for secondary
care. OECD Health Data do not suggest a shift of resources towards the primary
care sector and outpatient care. In some countries (Finland, France, Iceland,
Italy, Luxembourg, Netherlands, Spain, Switzerland, Belgium and Turkey), the
proportion of total health care spending devoted to outpatient care throughout
the 1990s has remained relatively stable or has decreased. Only two countries
have significantly increased the proportion of resources channelled to outpatient
care: Austria (+ 6 %), and Denmark (+ 3 %) (OECD, 2004).
GP density
Tracking the distribution of the workforce between levels of care is a way to
obtain evidence on possible changes in the accent on primary and secondary
care. Available data on the supply of physicians do not suggest growth in the
proportion working in primary care. The density of GPs across Europe is shown
on the map in Figure 2.1 (see plate section) and also in Table 2.1.
The map shows considerable variations across countries. Countries with most
GPs per 1000 population in 2002 are Austria, Belgium, Finland and France. The
lowest densities are found in Latvia, Poland, Slovakia and Switzerland. Details
on the number of GPs per 1000 population both in 1990 and 2002 are given in
Table 2.1.
Comparison of the figures from 1990 and 2002 shows that the numbers have
remained relatively stable in most countries. In 10 out of 19 countries for which
data were available for both years there has been an increase in GP density, with
a relatively strong increase in Austria, Finland and Norway. In eight countries
the density was the same in both years. Only in Portugal only was there a
decrease in the number of GPs in relation to the population. Countries with a
GP referral system have been indicated in the table, as this feature can be taken
as an indicator for a well-developed primary care system. The table shows that
GP referral systems are not related to a high or low GP density. Between countries with such a referral system there is also a considerable variation. Within
this group, in Norway and Italy the number of GPs per 1000 population is
about double the number in Netherlands, Portugal and Slovenia. Concerning
nurses, no current data are available to estimate what proportion are involved in
primary care.
Income
Recruitment for general practice is influenced by the income that medical
students can expect to earn as a GP, compared to the income of medical specialists. Differences in income reflect differences in status between medical
specialties. Existing data suggest that physicians’ incomes, both generalists and
specialists, are in general in the top 25% of the population, similar to senior civil
servants (Anderson, 1998; OECD, 2000; Reinhardt et al., 2002). However, there
is enormous variation between countries. Physicians in western Europe receive
higher compensation than their colleagues in central and eastern Europe. GPs’
30 Primary care in the driver’s seat?
Table 2.1 Number of GPs per 1000 population in European countries in 1990 and 2002
Countries
Austria
Belgium
Czech Republic
Denmarkg
Estonia
Finland
France
Germany
Hungary
Icelandg
Irelandg
Italyg
Latvia
Lithuania
Luxembourg
Netherlandsg
Norwayg
Poland
Portugalg
Slovakia
Slovenia
Sweden
Switzerland
Turkey
United Kingdomg
GPs per 1000 population
19901
20021
1.1
1.9
0.7
0.6
n.a.
1.3
1.6
1.1
0.7
0.6
0.5
0.9
n.a.
n.a.
0.8
0.4
0.7
n.a.
0.7
n.a.
n.a.
0.5
0.4
0.5
0.6
1.4
2.1
0.7
0.7
0.7
1.7
1.6
1.1
0.7
0.7
0.6
0.9
0.4
0.7
0.9
0.5
1.1
0.2
0.5
0.4
0.5
0.5
0.4
0.7
0.6
Difference 1990–2002
+0.3
+0.2
0
+0.1
n.a.
+0.4
0
0
0
+0.1
+0.1
0
n.a.
n.a
+0.1
+0.1
+0.4
n.a.
−0.2
n.a.
n.a.
0
0
+0.2
0
Note: g Countries with referral system/patients registered with a GP
1
Or nearest available year.
n.a. = not available / not applicable
Sources: OECD (2004), Arnoudova (2005).
incomes have been increasing in many countries over recent years, but data
available for a few OECD countries show a gap between average physicians’
income (specialists and generalists) and average GPs’ income in most of these
countries (OECD, 2000). In some countries such as Norway, systematic efforts
have recently been made to narrow the income gap between generalists and
medical specialists (Furuholmen and Magnussen, 2000).
In all countries, the average income among physicians was superior to the
average income among nursing and midwifery professionals (OECD, 2000). In
general, physicians’ average wages go up to more than twice as high as wages for
nursing and midwifery professionals (Gupta et al., 2002). There are no specific
data on primary care nurses.
Although more accurate and thorough information is clearly needed to tease
out the issue of the distribution of resources between the different levels of care
in Europe, the evidence to date suggests several conclusions:
Mapping primary care across Europe
31
• an
•
•
•
absence of significant changes in the financial resources allocated to
primary care;
an unequal density of GPs across European countries;
little or no change in most countries in GP density between 1990 and 2002;
a financial situation that in most cases continues to be more favourable to
medical specialists than GPs.
Mapping primary care practice in Europe
To what extent do primary care systems in Europe comply with our definition?
Is there one single point in the health system where first contact care is provided
with a generalist approach from a long-term perspective? To what extent have
nursing disciplines developed and been integrated into the context of primary
care? Are services available in patients’ homes? Are providers collaborating and
are their interventions coordinated? It will be difficult to answer all these questions, because, here again, the available information is not up to date and not
sufficient to provide answers.
The first part of this section briefly reviews the general organization of home
care activities in 15 European countries, and to a lesser extent their provision.
The information reflects the situation in these countries in the mid-1990s and
has been derived from an international study (Hutten and Kerkstra, 1996). The
remaining part of this section describes the organization and provision of
services in general practice in 32 countries in Europe, based on a 1994 study
(Boerma et al., 1997; Boerma and Fleming, 1998; Boerma, 2003).
Home care
Ageing populations and societal developments result in increasing demand
for professional home care in Europe. The old and very old are a growing proportion of the population. As family size decreases and mobility increases the
availability of relatives for informal care will continue to decline. Moreover,
substitution policies in health care result in the transfer of tasks from hospitals
to the home situation. Consequently, home care is increasing both quantitatively and qualitatively (Tjassing et al., 1998). In the countries of central and
eastern Europe, home care is a relatively new concept; however, it is now being
developed in a number of these countries as part of primary care (Vladu, 1998;
Fedullo et al., 2004).
A variety of disciplines provide medical, nursing and domestic care in the
home situation. GPs make home visits as do practice nurses in some countries.
Social and geriatric services may also visit their clients at home, and churches
may be involved as well. The European study of Hutten and Kerkstra (1996)
focused on structurally embedded care provided at home by professional organizations. It was limited to two core disciplines: home nursing and home help
services. Home nursing included rehabilitative, supportive, promotive or preventive and technical nursing and was mainly aimed at sick people at home.
Preventive mother and child care, school health nursing and occupational
32 Primary care in the driver’s seat?
nursing were not covered by this study. Home help services included housework, such as cooking, cleaning, washing, shopping, personal care and administrative paperwork. Organizations for the provision of only one item of service,
such as “meals on wheels”, were not included.
The assessment of needs with “patients” or “clients” is an important first contact function in home care, related to the mode of funding. In countries where
home care is prescribed by a physician, such as in France, he or she may be the
one to decide what care is needed. In many other countries needs assessment
and the delivery of care are not separated and are carried out by an employee of
the home care organization involved (Parry-Jones and Soulsby, 2001). In the
Netherlands, where no referral is needed for home care, since 1998 broad needs
assessment has been undertaken by independent assessment agencies. The
Netherlands has also introduced uniform assessment instruments in order to
make the intake procedure more objective (Algera et al., 2003).
Home nursing
In the 15 countries of the pre-2004 EU, home nursing is usually part of the
health care system, but it is organized, quite differently often reflecting historical development. In Belgium, Denmark, Finland, Ireland Netherlands and the
United Kingdom, home nursing has a long tradition, while it is still only developing in Austria, Greece, Italy, Luxembourg, Portugal and Spain. Also, organization is not always uniform within countries. There may be two or more modes
of organization or circuits, for instance parallel provision by municipalities,
non-profit organizations, hospitals, charity associations, and initiatives affiliated
with political parties, in addition to independently established nurses.
Organizations for home nursing are usually not-for-profit. However, with the
introduction of market elements in health care for-profit organizations have
also entered the sector. Basically, there are two funding models. In one, resources
come from general taxation with fixed budgets for the organizations. The size of
the budget is usually related to the number and composition of the inhabitants
in the working area. In countries with this funding scheme, such as Denmark,
Ireland, Italy, Portugal and Spain, patients do not need a referral for home nursing. In the second model, where resources have been collected from social
health insurance premiums, a fee-for-services scheme is used. In these cases
(Austria, Belgium, France, Germany) patients need a referral from a physician.
The assessment of need for home nursing differs in both funding schemes. If
no referral is required, needs are assessed by the home nursing organization,
while in the second model needs are usually assessed by the referring physician.
Payments can be based on different mechanisms. In the case of fee-for-service
payment, services have been specified in a nomenclature; a list of (technical)
nursing activities. In a pay-per-home visit scheme, usually two types of visits
(and tariffs) are distinguished: those for personal hygiene and those for technical nursing. Another option is payment per patient for a fixed period of
time, for instance one month. The level of payment is then determined by the
assessed needs of the patient. Mixes of these modes of payment also occur,
either with or without co-payment by the patient.
Concerning human resources in the provision of home care, usually two levels
Mapping primary care across Europe
33
of expertise are distinguished: a lower level nurse more involved in personal
hygiene and uncomplicated nursing tasks and a higher level nurse for more
technical nursing and complex situations.
Home help services
In contrast to home nursing, home help services are not a part of health care but
are considered as social services, except in Ireland, the Netherlands and to some
degree in Germany. In Greece and Italy home help services started to develop
only in the early 1980s, while in other countries it has had a longer tradition.
In most countries home help services are organized by local authorities, such
as municipalities and no referral is needed. Needs are assessed by an organizer
or team leader of the home help organization who is usually a social worker.
In cases where home nursing and home help services are integrated in one
organization, as in the Denmark, Ireland and Netherlands, home nurses
may also assess the patients’ need for home help. Since the mid-1990s there has
been a trend towards integrating home care nursing and home help services.
There is increased collaboration and there have been mergers between these
organizations.
The workforce in home help services is large, but the level of required education
is relatively low. In most countries there is little formal training for home helpers – they may have had a short course or have been trained on the job. There are
enormous differences in the availability of home helpers, as Table 2.2 shows.
The supply of home helpers in countries like Belgium, Denmark, Finland, the
Netherlands and Sweden is at least 10 times the supply in Italy, Luxembourg
and Spain (referring only to the Genoa region, since in the south of the country
home help services are even less developed). In countries with relatively few
home helpers, informal care plays an important role in the provision of personal
and domestic assistance to relatives, friends and neighbours.
Table 2.2 Number of full-time home helpers per 1000 population in European countries
Country
Population per home helps per 1000
population
Austria (Vienna area)
Belgium (Flanders)
Denmark
Finland
France
Ireland
Italy (Genoa area)
Luxembourg
Netherlands
Spain
Sweden
United Kingdom
1.34
2.23
6.21
1.89
0.71
0.86
0.18
0.16
2.01
0.20
9.01
0.91
Source: Hutten and Kerkstra (1996).
34 Primary care in the driver’s seat?
In many countries both home nursing organizations and home help services
reported problems in efforts to collaborate with hospitals, GPs and other
services in primary care, and with social services. The most frequently reported
complaints were lack of information and poor communication with patients
transferred from one level or service to another or concerning joint patients
(Hutten and Kerkstra, 1996).
General practice
General practice has the potential to be the core of primary care, but this potential is utilized to different degrees in European health care systems. Arguably
the strength of primary care very much relates to the strength and position of
general practice in a country. Many elements of our working definition of
primary care apply to services provided in general practice if it is well positioned
in a health care system.
The position and strength of general practice in Europe will be discussed in
light of our working definition. In particular, the focus will be on the following
elements: the role of GPs as the doctor of first contact for a broad spectrum of
health problems; the range of curative and preventive services offered to
patients; the available medical equipment to allow diagnostic services and
treatment; mono- and interdisciplinary cooperation; and conditions favouring
continuity of care.
Information for this comparison is from the European study of GP Task
Profiles, in which well over 8000 GPs in 32 countries answered detailed questions on the organization of their practice and the provision of services (Boerma
et al., 1997; Boerma and Fleming, 1998; Boerma et al., 1998). Data were collected
in 1994 and so changes may have taken place in a number of countries since
then. This will be particularly true in countries in central and eastern Europe
and should be taken into account when interpreting the results. However, the
study was recently replicated in one of these countries and demonstrates that
the effects of health reforms on the task provision of doctors in primary care
should not be overestimated. Another indication of the relative stability of GP
services over time are the results from the Second Dutch National Study in
General Practice, which were recently updated 14 years after the first edition.
The results indicate that GPs work more efficiently now, for example by delegating tasks to other providers of out-of-hours care, and a slight decrease in specialist referrals suggests a higher level of curative activities in primary care. In
general, however, there are no indications of fundamental change. All groups in
the population still find their way to the GP and the gatekeeping role of GPs is
unchanged (Schellevis et al., 2004).
Results by country are presented by maps with colours representing the ranking of the country regarding aspects of GP task provision, as mentioned above.
Tables with the rank positions per country are in the annex at the end of this
chapter. In these tables, the countries have been listed according to three
categories: those with a tax-funded health system, those with a social health
insurance system and the countries in transition located in central and eastern
Europe.
Mapping primary care across Europe
35
First contact care
The five columns on the left-hand side of Table 2.A in the annex show data on
the role of general practice as the entry point of health care. This role was
measured by means of 27 short case descriptions about which GPs could answer
according to a four-point scale regarding the extent to which a problem would
be presented first to the GP when it would occur in the practice population. Four
dimensions could be identified according to the type of health problem: acute
problems, problems specific to children, those specific to women, and psychosocial problems. The first column in Table 2.A shows the overall ranking with
respect to the total list of problems. This has also been depicted in Figure 2.2
(see plate section). The second to the fifth columns give the countries’ position
as regards the subcategories.
Countries with GPs in a strong position as the entry point of health care appear
to be the Denmark, Ireland, Netherlands, and the United Kingdom, followed at
a short distance by Norway, Portugal and Spain. It is not surprising that these
are countries with GPs in a gatekeeping position, since this role generally
requires health problems to enter via the GP. The transitional countries have the
lowest rankings, however, with the exception of Croatia and Slovenia, which are
the only transitional countries with gatekeeping GPs.
The highest ranking countries also are strong in terms of the point of entry
when subcategories of problems are considered (see Table 2.A). This appears to
reflect a stronger position in terms of first contact with problems related to
children and women. In the other countries, it seems that for these problems people bypass GPs. For first contact with acute health problems, for
instance, the role of GPs is similar irrespective of their gatekeeping position. In
most transitional countries, GPs have a much weaker entry position, but with
respect to first contact with acute problems this gap is smallest. The differences
between countries with tax-funded health services and those with social health
insurance schemes seem to be evident, but can be attributed to the fact that
tax-funded health systems more often have GPs in a position as gatekeeper.
Ireland and the Netherlands are both social health insurance countries with
gatekeeping GPs and interestingly, both countries are in the highest ranking
group.
Generalism and comprehensiveness
General practice is not only the place where health problems are presented,
but also diagnosed and treated. This is true for acute cases as well as for chronic
diseases. Comprehensiveness and generalism refer to the range of curative
services provided by GPs, as well as his or her role in the domain of prevention
and health education (Calnan et al., 1994). The following groups of activities by
GPs were taken into account. First, involvement in the treatment of diseases.
This was measured by means of 17 short case descriptions about which GPs
could respond according to a four-point scale. Second, the involvement of
GPs in the provision of medical technical procedures, including minor
surgical treatments, was measured. This was gauged by means of 14 questions
structured in a similar way to the questions pertaining to treatment of diseases.
36 Primary care in the driver’s seat?
Furthermore, the uptake of cervical smears and health education in clinics or
groups concerning smoking cessation, healthy diet or problematic drinking
was surveyed. Finally, the involvement of GPs in family planning was
measured.
The relative positions of countries on the comprehensiveness of the GPs’
curative and preventive services, as mentioned above, have been summarized in
Figure 2.3 (see plate section). Positions on each of the services can be found
in Table 2.A at the end of this chapter.
Considering all services together, Figure 2.3 shows that countries where GPs
provide the most comprehensive mix of services are mostly situated in western
and northwestern Europe. More specifically, these countries are: Austria,
Denmark, France, Germany (western), Iceland, Ireland, Norway, Switzerland
and the United Kingdom. Five of these countries have gatekeeping GPs, but
these are only half of the countries with GPs in such a position. Two countries
with gatekeeping GPs, Italy and Spain, are among the countries where GPs
provide a relatively small set of services, as in transitional countries such as the
Czech Republic, Poland and Romania.
Teamwork and cooperation
The provision of comprehensive services and coordination of care can be facilitated by teamwork and good working relations with other health care workers,
both in primary care and in secondary care and hospitals. In small scale (solo)
practices it may be difficult for GPs to provide a broad range of services around
the clock and to coordinate with care provided by others. Larger practices can
hire ancillary staff, purchase equipment more efficiently and have regular
meetings for coordination and joint policy-making. Group practices can be
seen as institutionalized forms of professional social control (De Jong et al.,
2003).
In most countries, general practice used to be dominated by individual practices. In most social health insurance countries the majority of GPs still work
in solo practices (see Table 2.B). Turkey is an exception in this group, and also,
though less so, the two gatekeeping countries (the Ireland and Netherlands).
Countries with few solo practices (less than 20%) are mostly found in the
tax-funded health system group: Finland, Iceland, Portugal, Sweden and the
United Kingdom. Italy, however, has a majority of solo practices and has gatekeeping GPs. In three transitional countries there are few solo GPs: Bulgaria,
Latvia and Ukraine. In this group of countries Poland is the exception with
many soloists.
Cooperation was further explored via questions about the prevalence of regular meetings (at least once per month) with colleague GPs, with ambulatory
medical specialists, with medical specialists in hospitals, with primary care
nurses and with social workers. Details have been reported in Table 2.B.
Taken together, the measures of collaboration with GPs, medical specialists
and other professional groups, the map in Figure 2.4 (see plate section) shows
the relative position of the countries.
Countries where GPs have relatively most intensive collaboration with other
professional groups tend to be at the periphery of Europe (see Figure 2.4). These
countries are: Bulgaria, Finland, Iceland, Latvia, Lithuania, Portugal, Sweden,
Figure 2.1 Density of GPs in Europe
Figure 2.2 Role of GPs as the doctor of first contact with health problems
Figure 2.3 Comprehensiveness of curative and preventive services by GPs
Figure 2.4 Collaboration of GPS with several disciplines
Figure 2.5 Medical equipment in general practice
Figure 2.6 GP’s sense of satisfaction
Mapping primary care across Europe
37
the United Kingdom and Ukraine. GPs in Belgium, Italy and Luxembourg have
few collaborative relations compared to GPs elsewhere.
Vignette 2.3 Slovenian primary care3
In the 1950s, under the influence of Andrij Stampar, the then socialist
government of Yugoslavia made large investments in primary health care.
A range of preventive activities were implemented: well-baby clinics, wellmother clinics, clinics for women, clinics for people with tuberculosis,
clinics for trachoma, clinics for workers, clinics for schoolchildren and
students, etc. Many of the physicians working in these clinics pursued
their professional careers in one of these specialist fields. Under these
circumstances, there was a decline in holistic and generalist thinking and
a polyclinic approach to health care, hence, general practice was on the
verge of extinction. Only a few enthusiasts believed in family medicine as
an important source of health care.
In the 1960s, family medicine (at that time known as general medicine)
was declared a specialist field, although vocational training was not a prerequisite for working in general practice. In November 1995, the Department of Family Medicine was established at Ljubljana University. It has an
unique curriculum. Four days each week, students meet with specially
trained tutors in a primary care practice to test their communication skills,
medical record keeping and other ordinary skills. One day a week,
students work with an assistant teacher in small groups presenting reports
about their experiences.
In 1992 Slovenia’s health care system was transformed from a state-run
system to a decentralized model with one insurance company, the National
Health Insurance Institute (NHII). Health care is provided by both public
(hospitals and primary health care centres) and private providers. Inhabitants of Slovenia are insured through their employment status and local
communities cover the unemployed. The compulsory health insurance
covers over 80% of all health care costs. Additional coverage is available
through voluntary insurance, which includes co-payments.
Patients must now choose their own ‘personal’ family physician. The
personal family physician has the responsibility to provide primary care
for their patients, which includes emergency care 24 hours a day provided
by physicians working in rotation outside of regular office hours. Family
physicians’ gatekeeping role also makes them a focus for cost containment
and quality assurance efforts. These goals could present a potential threat
to the quality of the doctor-patient relationship.
Family physicians work as independent contractors to NHII or
employees in non-for-profit Primary Health Care Centres (PHCCs) which
are group contractors to NHII. PHCCs are very evenly distributed
throughout the country and mainly located in the community centres.
The PHCC in Radovljica is a typical example of such a centre. Radovljica
lies in the north-west part of Slovenia, 50 km from the capital Ljubljana. It
38
Primary care in the driver’s seat?
is one of the 60 Health Care Centres (HCCs) in Slovenia and is neither the
biggest nor the smallest. PHCC Radovljica provides care for approximately
18,200 inhabitants.
Primary health in the Radovljica PHCC combines public and private
physicians. Nearly half of all employees are private with public contracts
and only one health care profession, acupuncture, is completely private.
Private medical staff receives money directly from the National Insurance
Company (ZZZS). The PHCC in Radovljica performs the following activities
and employs the following staff:
General practice
Paediatric and school medicine
7 GPs, 6 of them specialists
1 paediatrician, 1 specialist for
school med.
Occupational medicine
1 specialist
Dental care for adults
4 dentists
Dental care for children
2 dentists
Orthodontics
1 specialist
Physiotherapy
3 physiotherapists
Neurophysiotherapy
1 neurophysiotherapist
Gynaecology
1 gynaecologist
Otorinolaringology
1X/week otorinolaringologist
Ophthalmology
3X/week ophthalmologist
Acupuncture
every day; medical doctor
Medical care for imprisoned people 2X/week GP
This includes a certain number of nurses.
PHCCs provide on call, emergency and out of hours services. PHCCs
also provide medical care for the elderly in a home with 206 beds.
Approximately half of these beds are for elderly people needing specialized medical care but not hospital care. There is also a home for youth
with disabilities which has with 75 beds.
The owner of the PHCC’s premises is the municipality, except for two
family practice offices, which are a part of a new wing that private doctors
bought this year. The municipality has some influence on policy in the
PHCC, but is not very important. The PHCC is integrated with Primary
Care of Gorenjska (Gorenjska is a region, where Radovljica lies). The
PHCC of Radovljica has premises in several locations: the main building
and majority of offices are situated in Radovljica, there is a branch office in
Kropa (a village approximately 20 km from Radovljica); there are homes
for the elderly and people with disabilities, and two dental surgeries
located in primary schools.
An appointment system was introduced to make the services more
accessible to patients. However, primary health care services are already
very accessible, perhaps even too accessible since patients often walk in
without appointment. The visiting rates in the Radovljica PHCC are more
than eight times per year per person. Due to heavy workload and expansion of the cardiovascular programme, an additional family physician had
to be employed.
Mapping primary care across Europe
39
A few years ago a nationwide cardiovascular prevention programme
was introduced for 35–65-year-old men and for 45–70-year-old women.
Workshops to teach healthier lifestyle habits (smoking cessation,
weight control, healthy eating, physical activity, etc.) are offered for
people with more than a 20% risk of having a cardiovascular problem.
Patients also receive anticoagulant treatment and diabetics are seen in the
PHCC.
In conclusion, following a long history of investing in primary care the
health care system in Slovenia has had a relatively smooth transition to a
decentralized model that recognizes the importance of primary care to
continuity and the coordination of patient services.
Continuity of GP care
The following indicators are available for continuity of care: the percentage of
GPs in a country who visit their hospitalized patients, GPs actively involved in
evening, night and weekend services and GPs routinely keeping medical
records for (almost) all attending patients (see Table 2.B). Making home visits
has not been taken into account, because in all countries, except Turkey and
Finland, it was reported as a task by a large majority of GPs. Hospitalized
patients are visited by about three quarters of GPs in the Netherlands and
Belgium and by 40% to well over 50% in France, Italy, Portugal, Romania and
Ukraine. Such visits are rarely made by GPs in Denmark, Latvia, Norway, Slovenia and Sweden.
Countries where at least 80% of GPs are actively involved in out-of-hours
primary care (for instance, in a rota group) are the Austria, Belgium, Finland,
Iceland, Ireland, Luxembourg, the Netherlands, Sweden, Switzerland and the
United Kingdom (see Table 2.B). In contrast, only small minorities of GPs are
involved in these services in Croatia, Estonia, Italy, Lithuania and Poland. GPs
in countries with a social health insurance system appear to be more involved in
out-of-hours services than those in the tax-funded systems.
Keeping comprehensive medical records on a routine basis are indispensable
for maintaining continuity of care. In Finland, Germany, Luxembourg and
Switzerland records are kept routinely by more than 90% of the GPs. This is
also true for most countries where GPs hold a gatekeeping position, with the
exception of Italy and Spain, where it is reported by only 70% of GPs (see Table
2.B). Bulgaria, Greece and Romania rank lowest in this respect (around 40% or
less).
Practice equipment
The use of medical equipment was measured with a list of 25 items; GPs were
asked to indicate if it was available and used in the practice. The list included,
among other items: haemoglobinometer, blood glucose test, cholesterol meter,
ophthalmoscope, gastroscope, ultrasound, audiometer, peakflow meter, electrocardiograph, set for minor surgery and defibrillator. Equipment assumed to be
used everywhere, for example the sphygmomanometer, was not included. As
Figure 2.5 (see plate section) and Table 2.C show, GPs in Germany, Lithuania,
40 Primary care in the driver’s seat?
the Netherlands, Nordic countries and Switzerland have the most items of
equipment, 12 or more from the list. Relatively low levels of equipment (four
to six) are in general practice in the Czech Republic, Hungary, Italy, Poland,
Portugal and Romania. Thus, it can be surmized that although GPs in Italy and
Portugal are gatekeepers, they do not have much equipment in their practices.
Indicators of the availability of X-ray and diagnostic laboratory facilities
were the presence of appropriate equipment in the GP practice or externally,
with results available within 48 hours (see Table 2.C). Five of the countries
having most of the items from the list of 25 are here again in the group with
the highest scores (availability among at least 90% of GPs). These countries
are Finland, Iceland, Lithuania, the Netherlands and Sweden. In Belgium and
the United Kingdom more than 75% of GPs have X-ray and laboratory facilities at their disposal with quick reporting of results. Countries with high
levels of practice equipment but limited X-ray and laboratory facilities for GPs
are Austria, Denmark, Germany, Norway and Switzerland. GPs, particularly in
the Czech Republic and Poland, but also in Croatia, Hungary, Portugal and
Turkey are worst off in term of X-ray and laboratory facilities and practice
equipment.
Job satisfaction
The European Task Profile Study of general practice contained questions on
different aspects of job satisfaction. Most GPs indicated interest and enjoyment
in their work; only 14% would prefer other work. Seventy per cent of GPs
reported an administrative overload. Satisfaction about the balance between
effort and reward was not high overall, but quite low in the countries of central
and eastern Europe and in Portugal and Turkey (Boerma and Fleming, 1998).
About half of the GPs felt that some parts of their work did not make sense (this
is shown in Figure 2.6 (see plate section) and in Table 2.C).
The largest proportion of GPs who believe that parts of their work do not
make sense are in Bulgaria, Finland, Italy, Lithuania, the Netherlands, Portugal,
Romania and the United Kingdom. It seems that in countries where GPs are
gatekeepers, they are somewhat less satisfied on this respect than GPs in other
countries. The reason for this may be that gatekeeping GPs, as the regular point
of entry, cannot easily make a selection in their case mix to exclude tasks
regarded as less reasonable.
The state of primary care in Europe: conclusions
Probably more important than the evident great differences in general practice
across Europe is how these differences are related to the way health care and
primary care are organized in different countries. A number of conclusions can
be drawn from a European study (Boerma, 2003). The organization of a health
care system is an important determinant of the way primary care services
are provided. In countries with a referral or gatekeeping system, GPs generally
provide a more comprehensive range of services, although they work fewer
hours than GPs in countries with parallel access to medical specialists. In countries with self-employed GPs paid on a fee-for-service basis, the GPs are more
Mapping primary care across Europe
41
involved in the treatment and follow-up of diseases and they spend more of
their working hours on direct patient care than GPs in other countries. Salaried
GPs provide fewer treatment services than self-employed GPs. The prevailing
payment system also influences how GPs respond to varying workloads.
Furthermore, there is a consistent contrast between the post-communist countries and the western European countries. In the western European countries,
GPs have more comprehensive service profiles than in central and Eastern
Europe, particularly regarding point of entry into the health system and the
provision of medicotechnical procedures. Among post-communist countries
distinctions are also found between the countries of the “former Yugoslavia”
and countries previously belonging to the Soviet Union.
On the basis of these results, a number of implications can be drawn. The
chapters that follow will expand on these themes.
• Gatekeeping GPs are well positioned in the patient flow at the entrance to
•
•
•
•
health care systems to respond to a wide range of ordinary conditions. This
position favours a coordinating role. Many countries are currently examining
flexible forms of GP gatekeeping. In countries with gatekeeping GPs, this system is sometimes felt to be too rigid (for instance, in care for the chronically
ill), whereas some countries without a gatekeeping system are trying to
introduce one, initially on a voluntary basis.
With respect to coordination and continuity of care, a system in which
patients are registered with a GP appears favourable in that it offers a greater
likelihood that medical information will be stored in one place, than do
systems without patient lists. A patient list system is not sufficient, however.
Individual GPs need to keep comprehensive medical records and maintain
good working relations with other health professionals in primary and
secondary care.
The mode of employment and payment of GPs should strive for a balance
between meeting patients’ needs and avoiding overtreatment. Self-employed
GPs appear to be more active than salaried GPs, both in terms of services
offered and working hours. Services like preventive screening, which are not
demand-driven, are unlikely to be provided under simple capitation payment
systems, which means that additional target payments are needed.
There is a trend of expanding responsibilities in primary care, resulting from
task transfer from secondary care, as well as the stronger involvement of
primary care in screening, prevention and health promotion. If financial
obstacles for these services are removed, practices need to be prepared for
these increased activities. It has been demonstrated that practices with more
staff and equipment provide a wider range of services. Moreover, GPs working
in groups may be more efficient because they work fewer hours with similar
workloads.
Computerized medical records are not just helpful for coordination and in
providing continuous care to individual patients. A good practice database is
also indispensable for the systematic screening and follow-up of chronic
patients. Routinely kept medical records become a major source of information for epidemiological and health services research, and can help develop
the currently inadequate body of knowledge on primary care in Europe
(Rosser and Van Weel, 2004).
Table 2.A General practice: point of first contact care; generalist approach and comprehensiveness
Country
GPs’ role as first contact with health problems
Generalism/Comprehensiveness
all health
probl.1)
acute probl.2)
childr.
probl.3)
women’s
probl.4)
ps./soc.probl.5)
treatm.of
disease6)
technic.
proc.7)
cervical
screen.8)
health
educ.9)
family
plann.10)
1
2
3
2
2
1
1
1
3
1
2
2
3
2
3
2
3
1
3
2
1
2
3
1
1
1
1
2
2
1
1
2
3
2
2
1
1
1
2
1
1
3
3
2
2
2
1
2
2
1
1
3
3
2
3
1
2
3
2
1
1
1
2
1
4
1
3
3
1
1
1
2
3
2
2
2
1
3
3
1
4
2
2
1
3
1
1
3
2
1
1
2
3
1
3
1
1
3
3
1
2
2
2
3
1
3
1
2
4
2
2
2
2
1
3
1
2
4
2
2
2
2
1
3
1
3
3
2
2
2
3
1
3
1
3
4
2
1
1
2
1
3
1
2
4
1
2
1
1
1
2
3
1
4
2
2
2
2
2
2
1
1
3
3
2
2
3
2
3
1
2
4
2
4
3
1
4
4
4
3
4
2
1
2
2
1
2
1
1
3
Tax-funded health
systems
DenmarkG)
Finland
Greece
IcelandG)
ItalyG)
NorwayG)
PortugalG)
SpainG)
Sweden
United KingdomG)
Social insurance
systems
Austria
Belgium
France
Germany
IrelandG)
Luxembourg
NetherlandsG)
Switzerland
Turkey
Transitional
countries
Bulgaria
CroatiaG)
Czech Republic
Estonia
Hungary
Latvia
Lithuania
Poland
Romania
Slovakia
SloveniaG)
Ukraine
4
2
3
4
3
4
4
3
3
4
2
4
4
1
2
4
1
4
4
3
3
3
1
4
4
2
4
3
3
4
4
3
3
4
3
4
4
2
4
4
3
4
4
4
3
4
3
3
4
1
3
4
2
3
4
3
3
3
2
4
4
2
3
3
2
3
3
3
4
4
3
3
4
3
3
4
4
3
4
4
3
4
2
3
3
4
4
3
4
2
–
3
3
4
4
2
1
2
4
1
1
4
3
2
1
3
2
2
4
2
4
4
1
3
4
4
3
4
3
3
Note:
Ranking of European countries (1 = countries with highest average involvement scores; 4 = countries with lowest average involvement scores; 2 and 3 = countries
with intermediate scores)
G
Countries with GPs holding a gatekeeping position
1
All health problems (27 short case descriptions; answered on 4-point scale)
2
Acute problems (subscale on 5 cases, e.g. burnt hand, first symptoms of paralysis, sprained ankle, first convulsion)
3
Problems related to children (subscale on 5 cases, e.g. rash, enuresis, hearing problem, physical abuse)
4
Problems related to women (subscale on 5 cases, e.g. oral contraception, irregular menstruation, lump in breast)
5
Psycho-social problems (subscale on 5 cases, e.g. relationship problems, suicidal inclinations, work-related stress)
6
Treatment/follow-up of disease (4-point scale on 17 short case descriptions, e.g. hyperthyroidism, acute CVA, ulcerative colitis, myocardial infarction)
7
Medical technical procedures (4-point scale on 14 specified procedures, e.g. removal of wart, insertion of IUD, removal of rusty spot from cornea, joint
injection)
8
Involvement in taking cervical smears systematically (e.g in a community programme)
9
Involvement in groupwise health education or life style clinic on smoking, diet or alcohol intake
10
Involvement in family planning and contraception
Sources: Boerma et al. (1997), Boerma et al. (1998).
Table 2.B General practice: cooperation and continuity of care
Country
Teamwork and cooperation
Continuity of care
2 or more
GPs in
practice
regularly
meetings
with other
GPs1)
regular
meetings
with
ambulatory
specialist1)
regular
meetings
with
hospital
specialist1)
regular
meetings
with
PC nurse1)
regular
meetings
with social
worker1)
% GPs
making
hospital
visits2)
% GPs
active in
out-of-hours
care3)
% GPs keeping
comprehens.
medical
records4)
2
1
3
1
4
2
1
2
1
1
4
1
3
1
3
4
1
3
1
2
4
2
1
3
3
4
3
4
4
3
4
3
1
3
1
4
2
4
4
3
4
1
4
1
4
3
1
4
1
1
4
1
1
3
3
3
2
1
4
2
4
2
2
2
1
4
1
4
4
2
3
1
3
1
4
2
4
3
1
2
1
1
4
1
3
1
1
3
2
1
4
4
4
4
3
4
3
2
4
2
1
3
4
1
1
2
2
1
4
2
4
1
1
2
1
4
2
3
3
4
2
2
3
3
3
3
3
3
2
4
1
2
3
1
1
3
3
2
1
1
1
2
3
1
1
1
2
2
2
1
1
1
1
Tax funded health
systems
DenmarkG)
Finland
Greece
IcelandG)
ItalyG)
NorwayG)
PortugalG)
SpainG)
Sweden
United KingdomG)
Social insurance
systems
Austria
Belgium
France
Germany
IrelandG)
Luxembourg
NetherlandsG)
Switzerland
Turkey
4
1
1
4
1
4
1
4
2
4
2
3
3
2
2
3
1
3
1
3
3
2
3
1
2
4
2
3
2
1
1
2
2
3
4
2
1
3
3
3
4
2
1
2
2
2
2
3
1
3
3
2
4
1
2
4
3
3
2
2
2
1
3
3
4
1
3
1
3
3
2
3
1
1
2
3
2
2
4
2
2
2
1
4
3
1
1
3
4
1
4
3
3
3
2
4
3
2
1
2
4
1
4
4
2
4
2
3
4
4
3
2
2
3
4
1
1
1
2
1
2
2
4
1
2
3
Transitional
countries
Bulgaria
CroatiaG)
Czech Republic
Estonia
Hungary
Latvia
Lithuania
Poland
Romania
Slovakia
SloveniaG)
Ukraine
Note: Ranking of European countries (1 = countries with highest average involvement; 4 = countries with lowest average involvement scores; 2 and 3 = countries
with intermediate scores)
G
Countries with GPs holding a gatekeeping position
1
Regular meetings at least once per month
2
GPs who visit their hospitalized patients
3
GPs involved in evening, night and weekend services
4
GPs routinely keeping medical records for (almost) all attending patients
Sources: Boerma et al. (1997), Boerma et al. (1998).
Table 2.C General practice: medical equipment and diagnostic facilities; job satisfaction
Country
Tax funded health
systems
DenmarkG)
Finland
Greece
IcelandG)
ItalyG)
NorwayG)
PortugalG)
SpainG)
Sweden
United KingdomG)
Medical equipment and diagnostic facilities
Job satisfaction
Medical
equipment1)
X-ray2)
Labo2)
Work makes sense3)
1
1
3
1
4
1
3
3
1
2
3
1
2
1
2
4
4
2
1
1
3
1
2
1
2
4
4
3
1
1
3
4
2
1
4
1
4
3
2
4
2
2
2
1
2
2
1
1
3
4
1
2
4
1
3
1
4
3
4
1
2
3
1
3
1
4
3
1
3
2
1
2
2
4
1
3
2
3
4
2
3
2
1
4
4
3
2
4
3
4
4
3
3
3
1
4
2
2
3
2
3
3
4
2
3
3
1
4
2
3
1
2
4
1
2
3
2
1
4
3
4
1
3
3
Social insurance
systems
Austria
Belgium
France
Germany
IrelandG)
Luxembourg
NetherlandsG)
Switzerland
Turkey
Transitional
countries
Bulgaria
CroatiaG)
Czech Republic
Estonia
Hungary
Latvia
Lithuania
Poland
Romania
Slovakia
SloveniaG)
Ukraine
Note: Ranking of European countries (1 = countries with highest average scores; 4 = countries
with lowest average scores; 2 and 3 countries with intermediate scores)
Sources: Boerma et al. (1997), Boerma et al. (1998).
1
Medical equipment being used from a list of 25 items
2
X-ray/laboratory facilities within the practice or external with results within 48 hours
3
% GPs disagreeing with: “Some parts of my work do not really make sense”.
G
Countries with GPs holding a gatekeeping position.
Mapping primary care across Europe
47
Notes
1
2
3
This vignette was written by Richard B. Saltman.
This vignette was writen by Elvira Chirila, GP, Romanian coordinator of the Dutchfunded Matra programme and Jan C. van Es, MD, PhD, general coordinator Matra
programme.
This vignette was written by Marjana Grm, GP and Janko Kersnik, GP, Radovljica,
Slovenia.
References
Aguzzoli, F., Aligon, A., Com-Ruelle, L. and Frerot, L. (1999). Choisir d’avoir un médecin
référent. Une analyse réalisée à partir du premier dispositif mis en place début 1998 [Choosing
to have a gatekeeper. An analysis, starting from the first mechanism established in 1998].
Paris: CREDES.
Alban, A. and Christiansen, T. (1995). The Nordic Lights; New Initiatives in Health Care
Systems. Odense: Odense University Press.
Algera, M., Francke, A.L., Kerkstra, A. and Van der Zee, J. (2003). An evaluation of the new
home care needs assessment policy in the Netherlands, Health and Social Care in the
Community 11(3): 232–241.
Anderson, G.F. (1998). Multinational Comparisons of Health Care. Expenditures, Coverage and
Outcomes. Baltimore: Johns Hopkins University, Center for Hospital Finance and
Management (http://www.cmwf.org/usr_doc/Anderson_multinational.pdf, accessed
18 February 2005).
Arnoudova, A. (2005). 10 Health Questions about the 10. Copenhagen: World Health
Organization
(http://www.euro.who.int/eprise/main/WHO/InformationSources/
Publications/Catalogue/20040607_1, accessed 18 February 2005).
Belien, P. (1996). Health care reform in Europe, Pharmacoeconomics 10 (Supplement 2):
1994–1999.
Blanpain, J.E. (1994). Health care reform: the European experience, in Institute of Medicine (ed.) Changing the Health Care System: Models from Here and Abroad. Washington,
DC: Institute of Medicine.
Boerma, W.G.W. (2003). Profiles of General Practice in Europe. An international study of
variation in the tasks of general practitioners. Utrecht: NIVEL (dissertation).
Boerma, W.G.W. and Fleming, D.M. (1998). The Role of General Practice in Primary Health
Care. Norwich: WHO Europe/The Stationary Office.
Boerma, W.G.W., Groenewegen, P.P. and Van der Zee, J. (1998). General practice in urban
and rural Europe; the range of curative services, Social Science and Medicine 47:
445–453.
Boerma, W.G.W., Van der Zee, J. and Fleming, D.M. (1997). Service profiles of general
practitioners in Europe, British Journal of General Practice 47: 481–486.
Bundesministerium für Frauen, Jugend und Gesundheit (2000). Gesundheitsreform
2000 [Health Care Reform]. Berlin: Bundesministerium für Frauen, Jugend und
Gesundheit.
Chinitz, D., Wismar, M. and Le Pen, C. (2004). Governance and (self-)regulation in social
health insurance systems, in R.B. Saltman, R. Busse, and J. Figueras (eds) Social Health
Insurance Systems in Western Europe. Berkshire: Open University Press/McGraw-Hill
Education.
De Jong, J.D., Groenewegen, P.P. and Westert, G.P. (2003). Mutual influences of general
practitioners in partnerships, Social Science and Medicine 57(8): 1515–1524.
48 Primary care in the driver’s seat?
Dixon, A. and Mossialos, E. (2001). Funding health care in Europe: recent experiences, in
T. Harrison and J. Appleby, Health Care UK. London: King’s Fund.
Dixon, A., Langenbrunner, L. and Mossialos, E. (2004). Facing the challenges of health
care financing, in J. Figueras, M. McKee, J. Cain and S. Lessof (eds) Health Systems in
Transition: Learning from Experience. Copenhagen: World Health Organization/
European Observatory on Health Systems and Policies.
Dubois, C-A., McKee, M., and Nolte, E. (2005, forthcoming). Human Resources for Health in
Europe. Berkshire/New York: Open University Press/McGraw-Hill Education.
Evans, R.G. (1981). Incomplete vertical integration: the distinctive structure of the healthcare industry, in J. Van der Gaag and M. Perlman (eds) Health, Economics and Health
Economics. Amsterdam: North Holland Publishing Company.
Fedullo, E., Jansone, A. and Ignatenko, E. (2004). Innovative home care and hospice. Cross
partnerships in Russia and Latvia, Caring 23(1): 22–25.
Forrest, C.B. and Starfield, B. (1996). The effect of first-contact care with primary care
clinicians on ambulatory health care expenditures, Journal of Family Practice 43: 40–48.
Furuholmen, C. and Magnussen, J. (2000). Health Care Systems in Transition: Norway.
Copenhagen: WHO/European Observatory on Health Systems and Policies.
Goicoechea, J. (1996). Primary Health Care Reforms. Copenhagen: WHO Regional Office for
Europe.
Gupta, N., Diallo, K., Zurn, P. and Dal Poz, M. (2002). Human resources for health:
an international comparison of health occupations from labour force survey data.
Syracuse, NY: Syracuse University [Luxembourg Income Study Working Paper Series,
No. 331].
Helman, C.G. (1998). Culture, Health and Illness. Oxford: Reed Educational and Professional Publishing.
Hobbs, R.H. (1995). Emerging challenges for European general practice, European Journal of
General Practice 1: 172–175.
Hutten, J.B.F. and Kerkstra, A. (1996). Home Care in Europe. A Country Specific Guide to its
Organisation and Financing. Aldershot: Arena Ashgate Publishing Ltd.
Jepson, G.M.H. (2001). How do primary health care systems compare across Western
Europe? Pharmaceutic Journal 267: 269–273.
Lagasse, R., Desmet, M., Jamoulle, M. et al. (2001). European Situation of the Routine Medical
Data Collection and their Utilisation for Health Monitoring. Brussels: Université Libre de
Bruxelles.
Le Grand, J., Mays, N. and Mulligan, J.A. (eds) (1998). Learning from the NHS Internal
Market: A Review of the Evidence. London: King’s Fund.
Marrée, J. and Groenewegen, P.P. (1997). Back to Bismarck: Eastern European Health Care
Systems in Transition. Aldershot: Avebury.
McKee, M. and Healy, J. (2001). The changing role of hospitals in Europe: causes and
consequences, Clinical Medicine 1(4): 299–304.
Niemelä, J. (1996). Health Care Systems in Transition: Finland. Copenhagen: WHO Regional
Office for Europe.
OECD (1992). The Reform of Health Care: A Comparative Analysis of Seven OECD Countries.
Paris: OECD.
OECD (1995). New Directions in Health Care Policy. Paris: OECD.
OECD (2000). OECD Health Data 2000. Paris: OECD.
OECD (2004). OECD Health Data 2004: A Comparative Analysis of 30 Countries. Paris: OECD
(first edition).
OHE (2000). 12th Compendium of Health Statistics. London: Office of Health Economics
(OHE).
Parry-Jones, B. and Soulsby, J. (2001). Needs-led assessment: the challenges and the reality, Health and Social Care in the Community 9(6): 414–428.
Mapping primary care across Europe
49
Preker, A.S., Jakab, M. and Schneider, M. (2002). Health financing reforms in central
and eastern Europe and the former Soviet Union, in E. Mossialos, A. Dixon,
J. Figueras and J. Kutzin (eds) Funding Health Care: Options for Europe. Buckingham:
Open University Press.
Reinhardt, U., Hussey, P. and Anderson, G.F. (2002). Cross-national comparisons of health
systems using OECD data, Health Affairs 21(3): 169–181.
Rosser, W.W. and Van Weel, C. (2004). Research in family/general practice is essential for
improving health globally, Annals of Family Medicine 2 (s2–s4) (http://www.
annfammed.org/cgi/content/full/2/suppl_2/s2, accessed 16 March 2005).
Saltman, R.B. and Von Otter, C. (1992). Planned Markets and Public Competition: Strategic
Reform in Northern European Health Systems. Philadelphia: Open University Press.
Schellevis, F.G., Westert, G.P., De Bakker, D.H. et al. (2004). Nog altijd poortwachter. Rol en
positie van huisartsen opnieuw in kaart gebracht [Still being a gatekeeper. Role and
position of GPs mapped again], Medisch Contact 59(16): 622–625.
Tjassing, H., Kling, T., Janssens, P., Van Gorp, J., Bramall, J. and Bowman, A. (1998). Home
care business opportunities in Europe, Caring 17(9): 53–57.
Vehvilaeinen, A.T., Kumpusalo, E.A. and Takala J.K. (1996). A list system can help to
reduce the proportion of out of hours referrals for male patients, Scandinavian Journal
of Primary Health Care 14: 148–151.
Vladu, V. (1998). Home care in Romania: a whole new concept, Caring 17(R): 36–37.
White, K., Williams, T.F. and Greenberg, B.G. (1961). The ecology of medical care, New
England Medical Journal 265: 885–892.
WHO (2004). WHO European Health for All Database. Copenhagen: WHO Regional Office
for Europe, June.
chapter
three
Changing conditions for
structural reform in
primary care
Wienke G. W. Boerma and Ana Rico
Introduction
The 1970s and 1980s have witnessed many attempts in European countries to
enhance integration among primary care services and to improve coordination
with the specialist and hospital sector and with social services. These initiatives have demonstrated that there is room for experimentation and initiative,
producing extensive experience on possible policy options to solve wellknown problems of poor coherence among services in primary care. However,
implementation has not gone beyond the activities of motivated idealists. In
the meantime, since the 1990s, a new division of roles and new governance
mechanisms have combined to change the organizational character of health
care. New approaches to strengthening primary care need to take these
changes into account as part of the increased complexity and diversity in
health care.
Regulating health care and making reforms work is complex, not least because
it depends so much on the motivation of diverse professionals within the health
care system. The context of health governance is not only highly typical per
country but it is also changing. Increasingly, governments tend to refrain from
direct involvement in financing and provision of health care. In the domain of
regulation, governments are leaving the details to lower level authorities or to
other parties in health care. But governments can only make this shift from
“rowing to steering” to the extent that the other actors are capable of taking up
compensating roles.
Probably more than in other health care sectors, changes in primary care are
difficult to achieve. As we have seen, the units of provision are usually numerous and small. Also many disciplines are involved, each with their professional
Changing conditions for structural reform in primary care 51
backgrounds and employment status. Improving coordination and continuity
in this complex situation requires a mix of policy instruments and the involvement of authorities, financers and organizations of professionals at different
levels. This chapter reviews the kind of reform tools available, which in turn
influence recent developments in health sector governance. It also discusses
what it means for primary care to be accountable and what requirements are
necessary for stronger primary care to be realized.
Reform tools for primary care
At the level of health care organizations, governance is shared by managers and
health professionals to different degrees across countries, sectors and time
periods. As in the case of health system governance, the trend over the last
decades has been less towards “command-and-control”, management-centred
approaches, and towards more “steer-and-channel”, clinical governance
approaches. Organizational governance is heavily influenced by the regulatory
and financial environment, and by the actors operating within it: central,
regional and local authorities, funding bodies, organizations of professionals
and patients and individual health care workers. Regulation for effective
primary care, including potentials for coordination and continuity, deserves
special attention. Such primary care systems do not emerge spontaneously in a
laissez-faire environment. Rather, the system must be financed, planned and
regulated, at different levels, in such a way that primary care providers are willing and able to take responsibility for the health of the population assigned to
them (Groenewegen et al., 2002). Experiences in several countries have shown
that such approaches are not incompatible with current trends of more contractual freedom between providers and purchasers, more budgetary power for
primary care professionals (for instance for particular services in secondary care)
or the privatization of primary care practice.
Governance of health care organizations
In organizational terms, governance can be defined as the combination of two
tasks: (a) decision-making (also called coordination); and (b) guaranteeing
compliance (motivation and control). Organizational decision-making consists
of dividing tasks across units, and reintegrating them through coordination.
Governance is operating successfully when personal and organizational goals
are reconciled, and actors are effectively performing the agreed tasks. Individual
compliance can be achieved either through motivation (when actors perceive
tasks as beneficial or useful) or through control (where the execution of tasks can
be imposed on the actors) or a combination of both.
Organizational governance can be realized by means of three possible mechanisms: markets, hierarchies and networks (Williamson, 1985). In market situations, the central mechanism of coordination is prices, with the assumption
that there is a spontaneous diffusion of information on costs, products and
innovations. Motivation in markets is mainly achieved via financial incentives.
52 Primary care in the driver’s seat?
In hierarchies, coordination is mainly achieved through plans and routines,
often designed at the top of the hierarchy, by managers. In hierarchies, means of
guaranteeing compliance is through the hierarchical power held by managers,
and ultimately, the threat of dismissal. In networks (also called cooperation),
coordination is accomplished by interaction between interdependent actors; for
example, negotiation or collective decision-making on the distribution and
content of tasks. The means for realizing compliance in networks are less
straightforward than in markets and hierarchies, since networks rely heavily on
voluntary adherence to social norms (trust, reciprocity). Informal social control
plays an important part too: fear of loss of reputation on the one hand, and
threats of exclusion from the network, on the other.
When the applicability of these notions to primary care is examined, it should
be noted that features of the demand side as well as of the supply side make it an
atypical industry in which not all models of governance and coordination are
equally suitable (Webb, 1991; Scharpf, 1994). Market-based coordination is
adequate for certain purposes and under strict conditions, but price mechanisms are not effective, as a result of imperfect competition and asymmetry of
information. Such market failures need to be compensated for by complementary state regulation. Furthermore, competition in a market strategy should
not inhibit necessary joint working among competitors. An obstacle for hierarchical coordination is the flow of information. The top levels in hierachies
have difficulties in getting access to information from the lower levels. Furthermore, the division of labour in hierarchies tends to be strict and rather rigid,
creating relatively independent organizational units among which interaction
is difficult. Whenever coordination across hierarchical organizational units and
boundaries occurs, it is usually the result of network interactions. The public
sector is a favourable environment for network-like structures, because of its
relative stability and shared social norms (Webb, 1991; Scharpf, 1994).
Multi-level approach
For the achievement of network mechanisms of governance, which is an
indispensable strategy in strengthening primary care, regulation (and particularly self-regulation) is required at different levels. At system (national) level, the
scope of services provided in primary care is set by means of governmental rules,
incentives and standards. Professional bodies, regional authorities and health
insurers play, each according to their possibilities, a steering role at the intermediate level. At micro level, the behaviour of professionals can be influenced
by budgetary and social control mechanisms, for instance within group practices
(Groenewegen et al., 2002).
Governance in primary care, or at least within disciplines, is usually firmly
based on forms of self regulation and mechanisms of network interaction.
Organization of (medical) professionals at different levels plays a role in developing norms and maintaining adherence. At practice level, peer groups serve as
the last link in the chain of social control. Peer control, for instance in partnerships, has traditionally been the predominant mode of coordination, even
within health care systems with formally hierarchical governance structures,
Changing conditions for structural reform in primary care 53
such as the National Health Service-type (Goddard et al., 2000). Indeed, GPs
within partnerships are more similar in their behaviour, and to a lesser extent in
their attitudes, than GPs not working in such groups. This convergence appears
to be related to partner selection in groups and to the practice circumstances
(for instance, the availabilty of specialist inpatient care). So, medical practice
variation is patterned by social processes in partnerships and group practices
and by local circumstances (De Jong et al., 2003).
Using social interaction in peer groups appears to be a more effective quality
improvement strategy than just giving feed back without such an educational
context (Verstappen et al., 2004). Although social processes among peers may
also have less positive influences on the quality of services, partnerships and
group practices must be appreciated for the opportunities they offer to realize
types of network coordination. Since general practice in many countries is
mainly provided from single-handed practice, incentives for the merging of
practices would be a good step towards better conditions for primary care
coordination. The next step would be to facilitate effective peer review among
practitioners, supported by national and regional structures.
The role of professions
Medical professions are suited to making cooperative coordination mechanisms
work, given their common process of socialization (through medical education), the high salience of reputation, and their shared value system. After
graduation, professional colleges and associations are valuable for maintaining
this process by setting internal norms and defending the interests of the profession vis-à-vis other professions, the government, health insurers or other actors
in health care.
In many countries supervision of the quality of services has, to some extent,
been delegated to medical professional bodies. Examples are the maintenance
of medical discipline and regular procedures of accreditation and reaccreditation. Self-regulation, which fits well in decentralization, may be more comprehensive and extend to initiatives for quality assurance. The Netherlands,
with its “Polder model”, is a country with a relatively strong self-regulatory role
of professional organizations. Accreditation of continuing medical education
and the five year relicensing of GPs have been delegated to the profession. The
Dutch College of GPs has been active in practice-based research and has undertaken many quality assurance initiatives. For instance, a tool for mutual practice
visitation has been developed and implemented. Feedback from these – voluntary – practice visits resulted in marked changes in practice management of the
visited GP (Van den Hombergh et al., 1999). The development of professional
standards or guidelines is another example. In some countries national bodies
produce these, such the National Institute for Clinical Excellence (NICE) in the
United Kingdom. In the Dutch environment of shared power, guideline development has been a successful activity of the Dutch College of GPs. Enabled by
government subsidies since the early 1990s the College has produced a large set
of evidence-based guidelines, each developed by GPs and for the benefit of GPs;
centrally developed, tested on applicability with GPs and locally implemented.
54
Primary care in the driver’s seat?
Implementation of the guidelines has received much attention; evaluation
has shown that multi-level approaches with extensive support and feedback
are most effective for the acceptance and adoption of the guidelines (Grol, 1993;
Grol and Grimshaw, 2003). The dissemination and implementation strategy of
professional organizations usually differs from the approach used by independent bodies. Professional organizations, such as GP Colleges emphasize the
implementation and the acceptance of the guidelines more than national agencies do (Burgers et al., 2003; Hutchinson et al., 2003).
Against the merits of quality improvement through self-regulated cooperative
arrangements, a number of limitations and weaknesses should be mentioned.
First, its scope is limited to the borders of each discipline; interdisciplinary
coordination may be a subject for improvement, for instance with “transmural”
medical guidelines, but will probably remain exceptional, particularly between
medical and non-medical disciplines. Cooperation based on self-regulation may
even increase the inward directedness and not necessarily result in efficient
larger scale system coordination (Scharpf, 1994). Some of the barriers to efficient
coordination within network-type arrangements are especially prominent in
health care, namely, disregard of aspects perceived as less relevant (for instance
costs); distrust of actors outside one’s own network (for instance, other professions, including health care managers); and higher coordination power of
members with higher prestige (e.g. specialists versus general practitioners)
(Grundmeijer, 1996; Vehviläinen et al., 1996; Somerset et al., 1999). Another
limitation is the informal character of these arrangements, which creates
poor conditions for accountability and does not improve coordination in a
structural way. However, if supplemented by external incentives and stronger
management, cooperation becomes less informal and may gain in effectiveness.
Professional bodies also have an important role to play in health politics.
Many of the disadvantages of network governance can be attenuated or counterbalanced by appropriate regulation and financing mechanisms. Cooperation
between the state and primary care professional associations is critical to guarantee that adequate mechanisms are in play. For primary care professionals to
gain leverage over hospital colleagues, powerful, politically mobilized primary
care professional associations are essential. In countries in which primary care
associations are strong, their participation in policy-making is more active, contributing to policies which further strengthen primary care (Rico et al., 2003).
The reform context
During the 1990s, the field of primary care in Europe witnessed a wealth of
experiments and a variety of different organizational changes. To some extent
the diversity of reform strategies reflected the specific features of the primary
care field, such as the functional and structural diversity observed in Chapters
One and Two. However, the approaches were also related to the changing policy
paradigms within the health care sector. Considered from the perspective of
strengthening primary care, both internally and in relation to other levels of
care, reform initiatives can be categorized in three broad groups of strategies
(Rico et al., 2003):
Changing conditions for structural reform in primary care 55
(1) reforms that increase the power of primary care (as purchaser or coordinator) over other care levels;
(2) reforms directed at broadening the service portfolio of primary care (as provider); often these services are transferred from other levels of care;
(3) reforms dealing with supporting conditions (resources and control systems),
which are necessary to promote a stronger role for primary care.
The first two strategies affect the division of tasks in health care. The first implies
an extension of coordination power across the interface; secondary care services
become subordinate to primary care. The redistribution of tasks in the second
strategy may result in better coordination between existing and the newly transferred services within the primary care level. Supporting conditions, such as
measures to enhance collaboration and teamwork in primary care and other
organizational resources, are essential, but are particularly effective if combined
with measures from the two other groups.
Mixes of governance
The role of the state in health care differs from country to country and ranges on
a continuum from strong (“command-and-control”) to relatively weak (forms
of “steer-and-channel” regulation) (Saltman and Busse, 2002; Van der Zee et al.,
2004). In the 1980s and 1990s state dominance in health care decreased
in favour of the various options of steering and channelling. The extreme of
command and control, where the central government has full power over regulation, financing and provision of health care, has become increasingly unusual.
Where state authority in health care is shared, for instance with regional or local
authorities, it is termed decentralization. Through decentralization, regional and
local circumstances can better be taken into account. Power can also be shared
with NGOs or semi-state bodies, such as health insurance funds or organizations
of professionals. This type of delegation of power is called self-regulation. Advantages of self-regulation include a strong commitment to one’s own rules as well
as low administrative costs. Privatization applies to situations in which certain
tasks, usually the provision of services, are transferred from the public to the
private sector. In social health insurance systems, primary care is usually provided privately. Private provision typically requires stronger external supervision of quality. This inspection of privatized provision is not necessarily in
the hands of the state. The task of regular external review of quality of services
on the basis of fixed standards, which is accreditation or licensing, can also be
fulfilled by independent agencies (Saltman and Busse, 2002).
Relatively strong state involvement was traditionally found in those systems
funded through taxation and largely providing in-kind services to the population. However, private practice can also co-exist, for instance through GPs who
work under contract within the system, or parallel to the system in private
practice. In social health insurance systems, originally, the state had a more
facilitating role, for instance by harmonizing existing arrangements in health
care; health care provision being primarily left to private institutions and providers (usually not-for-profit), contracted by “sickness funds”. At present, it is
56 Primary care in the driver’s seat?
increasingly difficult to position particular health care systems on the basis of
this simple dichotomy, in that the nature and extent of relations between actors
have changed so much. Countries with tax-funded systems have experimented
with changes that promote consumer choice and responsiveness, encourage
competition among providers and increase resources for health care. The British
NHS is no longer the pure public delivery model that it used to be, and
the introduction of competing sickness funds has changed the character of
the social health insurance systems. In many countries during the past decades,
managerial control and market mechanisms have reduced the traditional power
of the professions, however, accountable professional organizations have
received new roles in the context of self-regulation. In central and eastern Europe,
reforms included the introduction of independent practitioners, new modes of
financing and payment with incentives to stimulate the provision of specific
services as well as engagement in continuing medical education (Dixon and
Mossialos, 2001).
Health system governance
Although there is some similarity among the general themes of reform programmes in different countries, this may not necessarily result in more similar
health care systems and structures of governance. The reform agendas have
common influences from international organizations such as the World Bank,
the OECD and the European Union, but details of implementation reflect different national structures. Convergence is challenged by an opposite trend of
increased power at the regional level (Defever, 1995).
The question is whether certain types of health care systems offer better conditions for change towards stronger primary care than others. As we have seen,
primary care is well developed in both the United Kingdom and the Netherlands, but health care governance in these countries is not easily comparable. In
the centralized British NHS the government holds a relatively strong position,
while decision-making in the Dutch context is determined by negotiation, consensus and compromise among actors. Yet, decisiveness seems to be stronger in
the centralized model, given, for instance, the greater success in the United
Kingdom in restructuring general practice into groups and later, in the 1990s,
the implementation of pro-primary care reforms that we have grouped under
category 1: the introduction of fund-holding schemes, later to be replaced by
the less market-oriented Primary Care Groups/Trusts. In contrast, the Dutch
policy on promoting integrated health centres in primary care has not been very
successful, the fundamental Dekker reform plans have never been implemented
and at present it is difficult to reinforce the agency role of the health insurance
funds in the Netherlands (Boerma, 1989; Schut and Doorslaer, 1999). Sweden,
with a tax-based system and largely public control and provision of services, has
implemented important reforms in the early 1990s. The Patient Choice and
Care Guarantee scheme laid grounds for competition between hospitals and
resulted in a reduction of the large waiting lists in those days. The Family Doctor
reform allowed GPs to start a private practice and patients could choose their
family doctor, either in private practice or in the polyclinic. This reform, as well
Changing conditions for structural reform in primary care 57
as other pro-competitive reform measures, were discontinued in 1994, when
the Social Democrats returned to power (Harrison and Calltorp, 2000; Quaye,
2001).
The German system, part of the Social Health Insurance group, is a federation with powers shared between central government, the Länder and nongovernmental corporate bodies (for instance the physicians associations and the
umbrella of the – hundreds of – sickness funds). Decision-making is quite separate among different parts of the health care system, with corporate institutions
particularly powerful in ambulatory and primary care. The German Government has not improved the position of family doctors in primary care, which is
still dominated by ambulatory medical specialists, and it has been difficult to
introduce a gatekeeping role for GPs (Busse, 1999; Wendt et al., 2004). In France,
ambulatory care is provided by privately established GPs and medical specialists, inpatient care is a public domain and funding is provided through social
health insurance. Policies on the rationing of access to care and the consumption of medicines have been hard to implement. During the 1990s, there were
initial attempts to control demand and improve quality of care, for instance, by
the introduction of voluntary patient health records (carnet de santé) and voluntary referring physicians, a kind of gatekeeping system (médecins référents)
(Lancry and Sandier, 1999). In 2005, however, a mandatory national gatekeeping system was introduced (Saltman and Dubois, 2005).
It is plausible that centralized systems could push through structural reforms
more easily while reform processes in countries with “shared power” may
proceed more incrementally (Saltman and Figueras, 1997), but these examples
do not provide strong support to this supposition. Using dichotomies such as
central versus decentralised schemes or state versus market orientation may be
oversimplistic. Overall, the introduction of market elements has changed the
role of governments in all health care systems. Boundaries between the public
and the private sector are blurring; however, the introduction of private sector
approaches is only compatible with sufficient government regulation to safeguard principles of equity and solidarity. The role of the state has changed,
though it has not been reduced. A suitable mix of governance requires a balance
between regulation and entrepreneurship (Defever, 1995; Saltman and Busse,
2002). Another reason why the traditional classification of health systems as
conditions for health reform is losing ground is the use of foreign best practice
models for health policy (Wendt et al., 2004). In financing there is a general shift
from public to private financing; in both tax-based and social insurance systems
the ongoing growth of health care expenditures will be realized in the private
sector. In regulation, health care systems tend to rely more on “uncommon”
coordination mechanisms. Social health insurance countries, for instance, continue to implement gatekeeping arrangements, which used to be associated
with tax-based systems. By introducing an internal market in the NHS, the
British government reduced direct regulation and increased the role of
competition.
58 Primary care in the driver’s seat?
Changing priorities
In the 1990s the focus of health policy has been on cost-containment, by means
of budget caps, expenditure ceilings and, in a number of countries, the introduction of market mechanisms (Saltman and Busse, 2002). It was expected that
coordination and coherence between services and levels of care would also
benefit from these measures. By the late 1990s these expectations turned out to
be too optimistic (Goddard et al., 2000; Rico et al., 2003). However, an interesting phenomenon could be observed in some countries where pro-competition
policies prevailed. Cooperative behaviour developed among health care organizations, rather than competitive behaviour, in order to face the problems
related to poor coordination (Goddard and Mannion, 1998; Harrison and
Calltorp, 2000). More generally, among health professionals and citizens, the
belief in the potential of market mechanisms has been reduced and countries
previously endorsing market-based reforms have started to be more open to
pro-cooperation policies (Busse, 2000; Harrison and Calltorp, 2000; Robinson
and Dixon, 2000; Donatini et al., 2001).
Towards new care arrangements
Attempting to formalize informal networks seems to be contradictory. A reduction of the informal character by transferring coordination power and resources
to a steering entity may arouse distrust and thus negatively affect the motivation of members. Yet interest in new forms of “managed cooperation”, with a
possible coordinating role of primary care, is growing. However, past experience
has taught that voluntary informal schemes are insufficient to this end. The
challenge is to design and implement policy instruments to promote cooperation and integration within primary care and across levels of care, based
on a mix of innovative market-like principles and more traditional hierarchical
measures, while leaving sufficient freedom to health care providers.
Culture of accountability
Developing a set of technical policy instruments may not be enough. There may
also be a need for a change of culture. This can be done with “implicit notions of
quality, building on the philosophy that the provision of well-trained staff,
good facilities and equipment [is] synonymous with high standards”. New
forms of leadership could empower teamwork, create an open and questioning
culture, and ensure that clinical governance remains an integral part of every
clinical service (Halligan and Donaldson, 2001). Indeed, the launch of clinical
governance, the British NHS programme of work to join up initiatives to
improve quality, has elicited high expectations. Clinical governance came in
1998 as a reaction to a number of medical scandals in the United Kingdom,
but also as a reaction to the situation in primary care, where some practices
were able to secure a wider range of services or faster access for their patients
than other practices. Clinical governance was not merely intended to improve
Changing conditions for structural reform in primary care 59
quality, but also to ensure it (Baker, 2000). Clinical governance is connected to
activities such as audit, evidence-based practice, continuing professional development, risk assessment procedures, critical incident reporting, and systems to
identify and help poorly performing professionals. The scheme was launched as
an organizational innovation requiring a cultural change in the health sector,
and senior managers of Primary Care Groups and Trusts seem to agree with this
view. They regarded a need for greater accountability as one of the most important aspects (Marshall et al., 2002).
Clinical governance is not an isolated development. There are more signs,
also in other countries, indicating that requirements concerning the quality of
primary care, including cooperation and continuity, are increasing. Participation in quality assurance activities, or in collaboration with colleagues, local
hospitals or home care services is no longer at the discretion of individual GPs.
Increasingly it will be a contractual obligation for practices and institutions to
account for their activities and the quality of their services to various stakeholders. Allen (2000) distinguishes between downwards accountability, upwards
accountability and horizontal accountability. “Downwards” refers to the local
community where the practice is situated. It can be realized by means of patient
participation. Upwards accountability is directed to the health care hierarchy,
for instance in Britain, the local health authorities; in social health insurance
countries, the health insurers with whom contracts are held. Horizontal
accountability is towards other providers in the practice or health centre or to
local providers of other disciplines (Allen, 2000). Major subjects of accountability are the process, which concerns the proper use of sound procedures, such
as records of patient care; the programme, which concerns the activities undertaken as well as their quality, for instance as proven by audits; priorities, referring
to the relevance and appropriateness of the activities chosen; and a financial
explanation, for instance the clarification of expenditure (Allen, 2000).
Tendencies towards growing accountability can be observed in a number of
countries. Current schemes for continuing medical education and procedures
for periodical re-accreditation of GPs are becoming more performance orientated, instead of input orientated (hours spent on CME activities). The term
“continuing medical education” is being replaced by “continuing professional
development” (see Chapter Nine, Heyrman et al.). In the Netherlands the government and medical professions are jointly developing schemes for measuring
performance in general practice. After these schemes have been established,
they can be used to allow patients to compare practices and thus make an
informed choice of their GP. Health insurers, who have the option of selective
contracting, can use the information to decide about contracts.
Not surprisingly there is a general need for performance indicators at all
levels of health care. Most indicators have been developed for clinical work;
but indicators on practice management can also enable patients and insurers
to compare services and providers (see Van den Hombergh et al., 1999). European
unification may demand indicators that can be used for international
comparison (Engels et al., 2005).
The growth of rational approaches, such as evidence based medicine and the
use of systematic evaluations (i.e. for the purpose of accountability) has resulted
in a need for increased research capacity. In the United Kingdom, for instance, a
60 Primary care in the driver’s seat?
national network of primary care organizations will be established to host
shared research management structures (Shaw et al., 2004).
In the past decade entrepreneurship and competition have increased in most
European countries, not least those in central and eastern Europe. This has not
been favourable for the development of strong primary care systems, which
are easier to develop in a less competitive and more regulated environment
(Starfield, 1996; Delnoij et al., 2000). Development of pro-primary care conditions, such as comprehensiveness, continuity and integration with other services
fits, better in an environment with accountable GP entrepreneurs who take
responsibility for care and coordination to a defined patient population
(Groenewegen et al., 2002).
Diversity or uniformity?
Current primary care arrangements in most European countries will have to go a
long way to be able to cope with the expanding range of services at primary
level, including continuity and coordination for complex care, and become
more accountable to their environment as well. Tasks and activities of individual practitioners and sectors need to be reconsidered and tuned. Many
experiments, supported by stimulating policies, have produced a wealth of
experience about possible future models of provision. Fifteen years ago a socalled scenario study on primary care and home care, commisioned by the
Dutch Government, formulated new patterns of primary care provision to solve
the problem of fragmented supply in the light of increasing demand for complex care (Steering Committee on Future Health Scenarios, 1993). Given the
pluriformity of Dutch primary care provision, the scenario team designed several possible models of organizational integration for complex care, based on
two dimensions: central versus decentralized control; and either observing or
not observing the traditional division of tasks between sectors and levels. Two
scenarios, the “extramural network” (with cooperation and coordination
among independent providers through agreements and protocols) and the
“extramural centre” (with stronger integration of providers and disciplines,
usually in shared premises) are purely primary care scenarios. Interestingly, the
extramural centre can either be built around an extended GP group practice, or
around other organization in primary care, for instance a home care association.
In the “transmural network” scenario, intramural organizations are more
closely involved, for instance nursing homes or hospitals (Steering Committee
on Future Health Scenarios, 1993).
This study suggests that there is no single best solution for a country; depending on local circumstances, different solutions can exist alongside each other. If,
despite incentives, a merger between primary care services is not feasible, a
federation may be an option. Furthermore, it is not necessarily general practice
that should take the lead; if home care is well organized it can be a better place
for coordination than small and fragmented general practice. In some countries
pharmacies are in a good position for a coordinating role, in particular in systems where patients are registered with a pharmacy and where these are well
(electronically) connected to GP practices. The above mentioned “transmural
Changing conditions for structural reform in primary care 61
network” has good possibilities for coordination across levels of care. But
primary care needs to be able to manage this type of coordination. If not, the
scenario proposes to put the “intramural” partner, the hospital or the nursing
home, in the driver’s seat. This points to the fact that pro-coordination innovations are not dependent on the availability of strong primary care. This is
in line with an international study on cross-level integration in nursing care
that found that such innovations took place both in primary care-oriented systems and in secondary care-oriented systems. The approaches, however, were
different (Temmink et al., 2000).
Requirements for primary care coordination
Central regulation is necessary to create preconditions and positive incentives
for primary care, but in itself it is not sufficient to achieve goals like better
coordination and continuity of care. Similarly, efforts from within the professions alone are not likely to be sufficient. As we have seen, a multi-level and
multi-actor approach is more promising. Thus, a first requirement for successful
primary care reform is that relevant actors at different levels, including governmental, non-governmental and professional, agree on policy aims and modes of
implementation. Furthermore, the aims and scope of reforms in a country are
obviously limited by the level of sophistication and development of actors and
their organizations and by current features of primary care. For instance,
attempts to implement fundholding schemes in the 1990s in central and eastern Europe were doomed to fail, above because recently introduced general
practice was unable to fulfil the related role. Similarly, it is useless to try to
expand the range of services in primary care if providers lack the competence for
it. In addition to requirements related to the health care system and the professions, there are conditions related to the practical working environment. These
three groups of requirements are elaborated below.
Conditions at system level
In addition to the general requirement of sufficient political and professional
support for changes, the central level is extremely important in setting general
conditions for primary care. An example of a notorious obstacle to coherence
and coordination are the different funding schemes prevailing in primary care.
Home care may be partly funded from the health care budget and partly from
the budget for social services. Cooperation between primary medical care and
social work is not only hampered because of different sources of funding, but
also because social services may have been delegated to lower level authorities
(for instance, municipalities) than other primary care services. Furthermore,
there may be poor grounds for cooperation if catchments – or working areas –
are not similar. This may be the case if the practice population of GPs is not
geographically defined, because patients are free to choose their GP, and community nurses are working in strictly defined areas. Many of these obstacles can
be taken away at central level. Another responsibility that should also be dealt
62 Primary care in the driver’s seat?
with is the education of professionals. Policy on curricula and volumes should
result in the production of sufficient numbers of providers – and no more than
that – who are prepared for their tasks in primary care (including cooperation
and coordination). Education for health care may be the joint responsibility of
the ministry of health and the ministry of education, a situation that may cause
conflicts. Planning the medical and nursing workforce is an important function
in order to avoid shortages or oversupply.
The position of general practice in the health care system is also a subject of
central regulation. If general practice is to play an important role in both
patients’ first contact and the coordination of care, its position needs to be
approved. A strong position for general practice is not readily compatible with
directly accessible medical specialists who compete with GPs to provide first
contact care (this can be solved by introducing a referral system). Similarly,
continuity of care requires that patients have appropriate incentives to see the
same GP for each new episode of care (this is usually realized with a patient list
system; patients register with a GP of their choice). As far as these arrangements
spoil market forces, appropriate incentives should be in place to eliminate the
potential disadvantages of this monopoly. If funding mechanisms are used for
regulation, health insurers have a role in addition to the government. The payment system may serve as an important vehicle for the incentives that can help
realize the objectives for primary care and general practice. Most powerful are
so-called mixed schemes, including a mix of basic payments (salary or capitation) with separate payments for certain additional tasks. Combined with
a gatekeeping role for GPs (and registered patients) this creates incentives
for delivering primary contact according to the principles formulated in Chapter One. Since payment systems may interact with other incentive structures,
such as performance monitoring, peer review and audit, fine-tuning may be
needed.
The professions
Self regulation by professional bodies has become an increasingly important
instrument in realizing health policy goals. It can only become important,
however, to the extent that these bodies are able to take up this role. This differs
between countries as well as between professions. The stronger the autonomy of
a profession (and the higher its status and recognition) the more significant the
instrument of self regulation may be (at the expense of hierarchical control).
The degree of recognition of general practice by other medical specialties in a
country is usually well reflected in its position in academia and education.
Where GPs have a weak position, their professional identity and professional
organization is weak, and their education relatively poor. Recognition follows
the following steps: firstly, its specific field of knowledge is accepted; secondly,
an academic body is established to develop this field of knowledge;
thirdly, those who practice produce literature that describes that knowledge;
finally, there is external recognition by the other medical disciplines, as well
as by the state and society as a whole (Pereira Gray, 1989). A strong role of
general practice in health care is related to advanced stages of recognition. Thus,
Changing conditions for structural reform in primary care 63
professional development, not only in general practice, but also in other professions, is a requirement for strong primary care. The process of professional recognition of general practice developed differently in Europe, with successes in
the Netherlands, Scandinavia and the United Kingdom and still marginal positions in countries like Austria, France, Greece and Italy. In several transitional
countries, active groups of GPs are catching up with western Europe (Lember,
1998; Švab, 1998; Švab et al., 2004).
In addition to academic efforts, professional recognition requires an organization for matters like registration, accreditation, quality assurance and professional discipline, and for external representation in negotiations and for
defending the material interests of the discipline. These activities, which are
important elements of self-regulation, are usually accommodated in the professional colleges and associations (Boerma and Fleming, 1998). Furthermore,
institutional coordination powers should be transferred to primary care
through state regulation. Last, but not least, the financial resources of primary
care professionals and associations are critical to guarantee their autonomy as
well as their market and political power (Rico et al., 2003).
Other primary care disciplines may not have reached the same level of autonomy, but the professional development pathway shows similarities. In various
countries nursing has developed from being an ancillary discipline to an
independent profession with several specialties and related education and training, including academic chairs in nursing science. In primary care the following
specialties have emerged: community nurses (sometimes called district nurses),
practice nurses and nurse practitioners. These nursing specialties have been
important in the expansion of tasks in primary care. Primary care nursing has
not developed well in all countries. In transitional countries, many nurses are
still “writing nurses” rather than “nursing nurses”.
The professional development of pharmacists, in some countries, has been
interesting for strengthening primary care. Especially in countries with welldeveloped primary care systems pharmacies have evolved from shops for the
delivery of medicines and related articles to points of information and coordination of pharmaceutical care. In systems where patients are registered with a
pharmacy, pharmacists are in a good position to give information and to
enhance compliance among patients. In the Netherlands, regular meetings of
pharmacists and GPs in the working area of drug prescribing policy have been
institutionalized. In this way pharmacies have become an active link in the
chain of primary care.
The practice environment
Proper housing is an important condition. The concentration of various
primary care services in shared premises may be efficient, create better cooperative and working conditions for staff and improve access for patients as well.
Although housing in most health systems is a local responsibility, there may
be supporting incentives at central level. Each primary care centre or practice
needs to safeguard physical access and availability of services to the patients;
to contract allied staff and to purchase the necessary equipment; to organize
64 Primary care in the driver’s seat?
cooperation with other providers in primary and secondary care; and to make
arrangements for continuity of care. Here also, incentives at central level
are indispensable in bringing about the desired working environment. The
remuneration system for GPs, for instance, may include targeted payments for
staff and equipment. Furthermore, there may be norms for the design of the
offices and organization of services; contracts may include obligations concerning opening hours and availability during evenings, nights and weekends.
Eventually it may be decided at operational level how primary care services are
provided to patients. Alternatively how accessible services are, which resources
are available, to what extent professionals cooperate; and whether or not
continuity of care is being observed. These aspects will be dealt with shortly.
Patients’ access should be available on a continuous basis and patients need to
be informed as to how to obtain care. Practice premises should be located within
a reasonable distance from patients’ homes. Access also includes provision for
out of hours and holiday services. The availability of necessary home visits is an
essential aspect of access. Effective home visiting requires ready access to patient
notes. If it is not the GP making the home visit, other professionals in the
primary care team can fulfil this role (e.g. the practice nurse). Patients must have
the option of consultation by telephone.
Teamwork and cooperation. Common working areas or boundaries of responsibility are prerequisites for cooperation. Training for effective teamwork can help
team members to surmount problems which are related to different status and
employment of team members; when some operate as independent contractors
and others are employed externally, for instance in associations for home care.
Cooperation between GPs and medical specialists deserves special attention. In
a gatekeeping system, GPs have a much stronger position in secondary care than
in systems where ambulatory specialists also provide primary care. Remuneration systems for GPs and specialists should be fine-tuned in order to avoid
perverse incentives.
Responsibilities for practice resources differ from system to system. Where GPs
are salaried the provision of practice premises and equipment is normally the
responsibility of the health authorities or municipalities. In contrast, where GPs
are independent entrepreneurs they are responsible for acquiring and developing adequate premises and equipment. Ancillary staff facilitates administrative
operations within the practice. Nurses are involved in medical technical
procedures and routine assessment of chronic patients and health education. In
larger units managers may be in place.
Computer facilities are particularly important. Computer files are increasingly
replacing paper records in many countries. However, the computer has more to
offer than records. It may provide an integrated information system for the
team and for secondary care. In this way it is an instrument for the continuity
and coordination of care. It also serves prevention, for instance the identification
and monitoring of groups at risk.
Continuity of care should avoid duplication of services and minimize the
chance of patients receiving contradictory opinions. Long-standing relationships between providers and patients are good conditions for giving health
education and enhancing patient compliance with therapies. Medical records
are essential for an integrated provision of services. They allow immediate
Changing conditions for structural reform in primary care 65
treatment of disease, serve as a reminder, define the risk status of the patient,
and can be used for practice monitoring, audit, research and teaching.
Competence is a major necessity for each professional. Competence is enhanced
by training and (continuing) education. The completion of specific training
followed by accreditation needs to be a condition for entry into general practice.
Procedures for periodic reaccreditation are a means of quality assurance. Evidence-based medicine has become an important approach for high quality and
cost-effective care. Research feeds the body of knowledge. Research achievements
should be disseminated not only among professionals to improve their competence, but also among policy-makers, insurers and health authorities to make
them aware of best practice and its conditions (Van Weel and Rosser, 2004).
Conditions for primary care that has potential for a coordinative role in
health care are numerous. Yet some specific elements stand out as key issues to
be addressed. Whatever the model of governance, countries resort to the same set
of policy instruments for restructuring primary care services: enhancing gatekeeping, developing teamwork, changing methods of remuneration of providers, increasing or reducing freedom of choice for providers and patients,
shifting the balance of centralization and decentralization, and changing the
balance between primary and secondary care. However, the options for reforming primary care in a particular country are not unlimited; there is only limited
room for a wholesale restructuring. As Mariott and Mable (2000) suggest in their
international review of primary care reforms, the evolution of the established
primary care systems in western Europe reflects a process of refinement of preexisting arrangements and continues to be consistent with their historical and
institutional development. Only the alarming situations in central and eastern
Europe have resulted in more rapid and substantial changes. For the rest, innovations are neither dramatic nor radical. Where important conditions for change,
such as the recognition of professions, are the result of a long process, no quick
structural changes can be expected.
References
Allen, P. (2000). Accountability for clinical governance: developing collective responsibility
for quality in primary care, British Medical Journal 321: 608–611.
Baker, R. (2000). Reforming primary care in England – again. Plans for improving the
quality of care, Scandinavian Journal of Primary Health Care 18: 72–74.
Boerma, W.G.W. (1989). Local housing scheme and political preference as conditions for
the results of a health centre-stimulating policy in The Netherlands, Health Policy,
13(3): 225–237.
Boerma, W.G.W. and Fleming, D.M. (1998). The Role of General Practice in Primary Health
Care. Norwich: The Stationery Office.
Burgers, J.S., Grol, R., Klazinga, N.S., Mäkelä, M. and Zaat, J. (2003). Towards evidencebased clinical practice: an international survey of 18 clinical guidelines programs,
International Journal for Quality in Health Care 15(1): 31–45.
Busse, R. (1999). Priority setting and rationing in German health care, Health Policy 50:
71–90.
Busse, R. (2000). Health Care Systems in Transition: Germany, Copenhagen: European
Observatory on Health Care Systems.
66 Primary care in the driver’s seat?
De Jong, J.D., Groenewegen, P.P. and Westert, G.P. (2003). Mutual influences of general
practitioners in partnerships, Social Science and Medicine 57: 1515–1524.
Defever, M. (1995). Health care reforms: the unfinished agenda, Health Policy 34: 1–7.
Delnoij, D.M.J., Van Merode, G., Paulus, A. and Groenewegen, P.P. (2000). Does general
practitioner gatekeeping curb health care expenditure? Journal of Health Services
Research and Policy 5: 22–26.
Dixon, A. and Mossialos, E. (2001). Funding health care in Europe: recent experiences, in
T. Harrison and J. Appleby (eds), Health Care UK. London: King’s Fund.
Donatini, A., Rico, A., Lo Scalzo, A. et al. (2001). Health Care in Transition Profiles: Italy.
Copenhagen: European Observatory on Health Care Systems.
Engels, Y., Campbell, S., Dautzenberg, M. et al. (2005). Developing a framework of, and
quality indicators for, general practice management in Europe, Family Practice 22: 1–8.
Goddard, M. and Mannion, R. (1998). From competition to cooperation: new economic
relationships in the National Health Service, Health Economics 7: 105–119.
Goddard, M., Mannion, R. and Smith, P. (2000). Enhancing performance in health care:
a theoretical perspective on agency and the role of information, Health Economics 9:
95–107.
Groenewegen, P.P., Dixon, J., and Boerma, W.G.W. (2002). The regulatory environment
of general practice: an international perspective, in R.B. Saltman, R. Busse and E.
Mossialos (2002) Regulating Entrepreneurial Behaviour in European Health Care Systems.
Buckingham/Philadelphia: Open University Press.
Grol, R.P. (1993). Development of guidelines for general practice care, British Journal of
General Practice 43(369): 146–151.
Grol, R.P. and Grimshaw, J. (2003). From best evidence to best practice: effective implementation of change in patients’ care, Lancet 362(9391): 1225–1230.
Grundmeijer, H. (1996). GP and specialist: why do they communicate so badly? European
Journal of General Practice 2: 53–55.
Halligan, A. and Donaldson, L. (2001). Implementing clinical governance: Turning vision
into reality, British Medical Journal 322: 1413–1417.
Harrison, M.I. and Calltorp, J. (2000). The reorientation of market-oriented reforms in
Swedish health-care, Health Policy 50: 219–240.
Hutchinson, A., McIntosh, A., Anderson, J., Gilbert, C., and Field, R. (2003). Developing
primary care review criteria from evidence-based guidelines: coronary heart disease as
a model, British Journal of General Practice 53: 691–696.
Lancry, P.J. and Sandier, S. (1999). Rationing health care in France, Health Policy 50: 23–38.
Lember, M. (1998). Implementing Modern General Practice in Estonia. Tampere: University
of Tampere, Acta Universitatis Tamperensis 603 (dissertation).
Mariott, J. and Mable, A.L. (2000). Integrated health organizations in Canada: developing
the ideal model, HealthcarePaper 1(2): 76–87.
Marshall, M., Sheaff, R., Rogers, A. et al. (2002) A qualitative study of the cultural changes
in primary care organisations needed to implement clinical governance, British
Journal of General Practice 52: 641–645.
Pereira Gray, D.J. (1989). The emergence of the discipline of general practice, its literature,
and the contribution of the College Journal, Journal of the Royal College of General
Practitioners 39: 228–233.
Quaye, R.K. (2001). Internal market systems in Sweden. Seven years after the Stockholm
model, European Journal of Public Health 11: 380–385.
Rico, A., Saltman, R.B. and Boerma, W.G.W. (2003). Organizational restructuring in European health systems: the role of primary care, Social Policy and Administration 37(6):
592–608.
Robinson, R., and Dixon, A. (2000). Health Care Systems in Transition: United Kingdom.
Copenhagen: European Observatory on Health Care Systems.
Changing conditions for structural reform in primary care 67
Saltman, R.B. and Busse, R. (2002). Balancing regulation and entrepreneurialism in
Europe’s health sector: theory and practice, in Saltman, R.B., Busse, R. and Mossialos,
E. (2002) Regulating Entrepreneurial Behaviour in European Health Care Systems.
Buckingham/Philadelphia: Open University Press.
Saltman, R.B. and Dubois, H.F.W. (2005). Current reform proposals in social health
insurance countries, Eurohealth 11(1): 10–14.
Saltman, R.B. and Figueras, J. (1997). European Health Care Reform: Analysis of Current
Strategies. Copenhagen: WHO Regional Office for Europe.
Scharpf, F. (1994). Coordination in hierarchies and networks, in F. Scharpf (ed.) Games in
Hierarchies and Networks. Frankfurt: Campus Verlag.
Schut, F.T. and Van Doorslaer, E.K.A. (1999). Towards a reinforced agency role of health
insurers in Belgium and the Netherlands, Health Policy 48: 47–67.
Shaw, S., Macfarlane, F., Greaves, C. and Carter, Y.H. (2004). Developing research
management and governance capacity in primary care organizations: transferable
learning from a qualitative evaluation of UK pilot sites, Family Practice 21: 92–98.
Somerset, M., Faulkner, A., Shaw, A., Dunn, L. and Sharp, D.J. (1999). Obstacles on the
path to a primary-care led National Health Service: complexities of outpatient care,
Social Science and Medicine 48: 213–225.
Starfield, B. (1996). A framework for Primary Care Research, Journal of Family Practice 42(2):
181–185.
Steering Committee on Future Health Scenarios (1993). Primary Care and Home Care
Scenarios 1990–2005. Dordrecht: Kluwer Academic Publishers.
Švab, I. (1998). General practice in the curriculum in Slovenia, Medical Education 32(1):
85–88.
Švab, I., Pavlic, D.R., Radic, S. and Vainiomaki, P. (2004). General practice east of Eden:
an overview of general practice in Eastern Europe, Croatian Medical Journal 45(5):
537–542.
Temmink, D., Francke, A.L., Hutten, J.B.F., Van der Zee, J. and Huijer Abu-Saad, H. (2000).
Innovations in the nursing care of the chronically ill: a literature review from an
international perspective, Journal of Advanced Nursing 31(6): 1449–1458.
Van den Hombergh, P., Grol, R.P., Van den Hoogen, H.J.M. and Van den Bosch, W.J.H.M.
(1999). Practice visits as a tool in quality improvement: acceptance and feasibility,
Quality in Health Care 8: 167–171.
Van der Zee, J., Boerma, W.G.W. and Kroneman, M. (2004). Health care systems: understanding their stages of development, in R. Jones, N. Britten, L. Culpepper et al. (eds)
Oxford Textbook of Primary Medical Care. Volume 1. Oxford: Oxford University Press.
Van Weel, C. and Rosser, W.W. (2004). Improving health care globally: a critical review of
the necessity of family medicine research and recommmendations to build research
capacity, Annals of Family Medicine 2 (suppl.2): s5–s16.
Vehviläinen, A.T., Kumpusalo, A. and Takala, J.K. (1996). Feed back information from
specialists to general practitioners in Finland, European Journal of General Practice 2:
55–57.
Verstappen, W.H.J.M., Van der Weijden, T., Dubois, W.I. et al. (2004). Improving test ordering in primary care: the added value of a small-group quality improvement strategy
compared with classic feedback only, Annals of Family Medicine 2(6): 569–575.
Webb, A. (1991). Coordination: a problem in public sector management, Policy and Politics
19: 229–241.
Wendt, C., Grimmeisen, S., Helmert, U., Rothgang, H., and Cacace, M. (2004). Convergence or divergence of OECD health care systems? TranState Working Paper
No. 9. Bremen: University of Bremen/Sfb 597 “Staatlichkeit im Wandel”.
Williamson, O.E. (1985). The Economic Institutions of Capitalism. New York: Free Press.
chapter
four
Drawing the strands
together: primary care
in perspective1
Richard B. Saltman
Primary care is one of the most complicated areas of European health care systems to assess and analyse (Boerma and Fleming, 1998; Boerma, 2003). Historically it has encompassed different activities in different countries, and has been
performed by different types of medical professionals with different types of
training: general practitioners, family doctors, community nurses, nurse practitioners, physician assistants, physiotherapists, polyclinic specialists, paediatricians and gynaecologists. Different primary care physicians have different levels
or even types of professional training: some are board-certified specialists,
others are not; some go through hospital rotations, others do not, and recently,
with the advent of primary care training programmes in central European countries, some primary care doctors were not trained as general practitioners, but
instead are rather hospital specialists with six months’ additional training.
Nursing and other disciplines in extended primary care also have been
developed to quite different degrees across Europe.
Organizationally, primary care has been structured in a host of different
arrangements. These cover the full spectrum, from being configured in some
countries as a for-profit business in the private sector to being structured in
other countries as a public service delivered by salaried civil servants. General
practice, as a core element in primary care, can be delivered in a wide range of
organizational settings: solo practice, group practice, primary health centres,
occupational health centres, and specialist polyclinics. Depending upon the
system and the country, its medical responsibilities range from first line curative
care focused on individual patients to both individual and population-level
prevention (Kark, 1981; Boerma et al., 1997; Starfield, 1998). In some health
systems, primary care sits at the centre of a complex primary health care system,
coordinating a wide range of nursing home and home care services; in other
Drawing the strands together: primary care in perspective 69
systems, primary care has little formal connection to any other primary health
care activity (Goicoechea, 1996).
All this diversity has made it difficult to settle on a universal definition to
describe primary care. As explained in Chapter One, this volume relies upon
Starfield’s functionally rather than organizationally defined framework, which
emphasizes what primary care does rather than who does it or in what part of
the health care system it is carried out (Starfield, 1998). This functionallyoriented definition fits well with one of this volume’s central characteristics,
which is its pan-European approach to primary care. This broader comparative
approach is one key factor that differentiates the preceding chapters from several other recently published, United Kingdom-focused studies of primary care
(Dowling and Glendinning, 2003; Peckham and Exworthy, 2003).
A second dimension on which this volume has taken a different direction is
visible in the pragmatic organizational focus of the issues discussed. The two
United Kingdom volumes noted above focus on the politics and/or ideology of
primary care and also primary health care reform, while two additional United
Kingdom studies, moving to the other end of the spectrum, examine qualityrelated, performance issues inside individual primary care practices (Van
Zwanenberg and Harrison, 2000; Marshall et al., 2002). In contrast, the authors
of this volume highlight the specific structural, personnel, and managerial configurations which exist and/or are possible within different organizational
arrangements, as well as the supporting conditions necessary to operate primary
care services efficiently and effectively. This emphasis fits well with the
volume’s broader cross-national approach. It also reflects this volume’s central
focus on key primary care policy-making issues currently under debate in a
number of European health systems.
This study’s cross-national and organizational perspectives serve to bring
into view the long-term development that primary care has undergone across
Europe over the past several decades. This perspective makes it possible to examine both the substantial organizational accomplishments of primary care to
date, as well as the policy challenges – old and new – that still remain to be
addressed. These two assessments, in turn, can then facilitate a more informative discussion of the central policy question raised by this volume’s title,
namely, whether primary care can be in the ‘driver’s seat’ in European health
care systems. Each of these three topics – organizational accomplishments,
policy challenges, and the driver’s seat question – will be considered in turn in
this chapter.
As a prelude to this discussion, it may be useful to review briefly the central
points raised in Chapter Five through to Chapter Twelve.
Drawing together the chapter contributions2
The evolving organizational arrangements in primary care across Europe can be
approached from a number of different perspectives. Changes have been under
way during the 1990s and first half of the 2000s in the institutional arrangements by which primary care is structured, in the work-life arrangements by
which primary care personnel deliver services, and in the quality standards that
70 Primary care in the driver’s seat?
influence the clinical and social appropriateness of the care delivered. Each of
these topics is developed in the volume’s expert, co-authored chapters. While
each category contributes to the overall assessment of organizational reform in
primary care, each also reflects sufficiently different components of the central
topic as to deserve separate consideration.
Changing institutional arrangements
The three chapters in this section (Chapters Five, Six and Seven) probe aspects of
the shifting interface between primary care and other sectors of the health service delivery system. All three lend support to an overarching perception that
internal organizational arrangements for primary care across Europe are at
present very much in flux.
This theme is clearly visible in Calnan et al. (Chapter Five) “The challenge of
coordinating,” which emphasizes three major points. The authors contend,
first, that gatekeeping had been useful in the past in encouraging integration of
services across the health system, and in particular for coordinating packages of
care. However, second, they argue that the basic concept of gatekeeping no
longer fits easily into a diversifying primary care world with large group practices, part-time GPs, specialist GPs, PC teams, and PC nurse triage. The chapter
lists five challenges that are likely to reduce the overall role of gatekeeping in the
medium term: 1) increased points of entry for patients to primary care; 2) single
electronic patient records difficult to implement across the entire health system;
3) patients may no longer know the treating GP (larger practices, part-time GPs);
4) emerging specialist GPs (e.g. dermatology); and 5) use of nurse triage for first
point of contact. All of these factors can be expected to dilute not only the
authority of gatekeeping, but that of the traditional GP as well. Indeed, this
profusion of non-GP-based points of entry into primary care suggests that the
traditional notion of GPs as the appropriate coordinators of primary care, as well
as of primary health care and hospital care more broadly, may be “outmoded”.
Following this line of logic to the next step, it may be that there will be increasing need for “new forms of coordination of care at the organization level, rather
than at doctor-patient level” (Calnan, 2002).
Following along from this view, the authors’ third observation is that a variety
of additional and/or alternative policies will probably be necessary to improve
the coordination role of primary care in the future. These new measures may
include: 1) specifying patient populations; 2) establishing a common package of
care for particular patient groups; 3) defining shared and separate responsibilities for primary care partners; 4) establishing clear financial arrangements
in advance; and 5) introducing training in information and communication
technologies in medical education.
Although they approach the shifting framework of primary care from a financial rather than an organizational perspective, McCallum et al. (Chapter Six) in
“The impact of primary care purchasing” develop along a parallel logical line.
The chapter focuses on the ability of different types of primary care led purchasing to influence both overall health system effectiveness and also the overall
system-level influence of primary care. They contend that, conceptually,
Drawing the strands together: primary care in perspective 71
primary care purchasing can streamline decision-making as well as improve
flexibility, timeliness and appropriate use of diagnostic services. They also
deduce that purchasing works best when primary care practitioners have the
clear ability to make choices about their financial liability and to control its
size. Although they argue that effective primary care purchasing needs to
combine clinical and financial decision-making so that spending reflects best
clinical practice, they note that neither the organizational nor the professional
conditions necessary to achieving this goal are currently met in most countries. Thus, just as Calnan et al. (Chapter Five) believe that gatekeeping is a
good idea that can no longer coordinate care adequately, McCallum et al.
(Chapter Six) find that primary care purchasing is a good idea but that most
countries don’t currently meet the necessary conditions to implement it
effectively.
The third chapter in this set looking at institutional arrangements is Sheaff
et al., “The evolving public-private mix” (Chapter Seven). These authors describe
a profusion of new variants in the delivery of primary care services, characterizing
this development as a major break with past patterns and traditions:
“New European forms of primary care provision have included medical
cooperatives; voluntary provision, including informal and self-care; ‘public
firms’; new forms of commercial primary care provision; non-medicalised
primary care (including ‘alternative’ and ‘traditional’ methods); and networked provision (four types: virtual primary care organizations around a
care pathway; professional networks promoting evidence-based medicine;
policy implementation networks; and ‘new public health’ networks under
WHO Healthy Cities).”
They trace the ongoing process of diversification in institutional arrangements
to the impact of competition and privatization, on the one hand, and to statepromoted implementation of networks as a way to enhance accountability
within primary care, on the other. The authors reinforce their first basic point by
suggesting that the introduction of benchmarking, contestability and other
instruments of competition have encouraged public forms of primary care to
experiment with new organizational models, which have the potential to
improve clinical quality and to better satisfy patients. Once again, although
Sheaff et al. (Chapter Seven) trace the source of increasing diversity of organizational forms and function to a different source – here, governmental policies
encouraging competitiveness and/or privatization – they support the broad
conclusion that primary care is metastasizing into a variety of new organizational
formats, without clear indication of a future dominant model.
Changing working arrangements
The second set of chapters (Chapters Eight, Nine and Ten) focuses on shifts
under way in the range and scope of the workload that GPs perform. The central
observation in all three is that the parameters of that workload vary considerably in response to a number of external needs and requirements, suggesting
that GP job profiles are at least as much the product of the broader society and
72 Primary care in the driver’s seat?
health system within which primary care sits as they are intrinsically generated
by clinical and/or preventive criteria.
Sibbald et al. (Chapter Eight) in “Changing task profiles” argue that shifting
work patterns for GPs can be attributed largely to forces in the broader society
and health care system. They identify five key factors which drive these
changes: 1) the broader organizational environment in the health care system; 2)
policy preferences for multi-dimensional professional teams, assuming that
these teams are more cost-effective; 3) payment systems that reward GPs for
adopting the desired changes; 4) training requirements from governmental
and/or professional bodies; and 5) attitudes of health professionals in renegotiating practice boundaries. The authors also examine specific organizational
measures by which changes in skill mix occur: enhancement, substitution,
delegation, and innovation. Further, the chapter notes that boundaries between
general practice and other patient services can be altered by processes of
transfer, relocation, and liaison. Ultimately, however, the authors conclude
that, since there is little convincing evidence about the superior cost effectiveness of one approach as against another, the particular configuration that
GP task profiles take appears to be contingent upon the specific circumstances
within a given country and its health care system. Thus, the shape of the
job GPs perform is likely to continue to vary over time and from country to
country.
These observations are reinforced in Heyrman et al.’s chapter on “Changing
professional roles in primary care” (Chapter Nine). The authors detail the wide
range of responsibility among government, universities, and professionals for
GP training and Continuing Medical Education, and the diverse criteria that
different countries set for the content and objectives of these educational activities. They also review the role of international organizations such as WHO and
WONCA in seeking consensus positions for training standards among these
diverse national actors. The authors observe that one particularly important
element for the future will be greater inclusion of a broader community orientation into professionally sponsored training activities. They conclude that if
professional self-regulation is to be maintained, it will require increased flexibility and adaptability to the new GP roles that are now emerging.
The third chapter in this set, on using payment systems to manage GP
behaviour, again suggests the fungibility of current thinking and tools regarding
primary care. Greß et al. (Chapter Ten) review traditional economic thinking
about behavioural responses to differing payment arrangements. Among other
important points, they note that the additional transaction costs associated
with close governmental regulation of integrated capitation systems should be
included in assessments of the relative overall efficiency of capitation as against
fee-schedule based approaches. Consistent with the two previous chapters, the
authors caution that payment systems work within – and in interaction with – a
broader institutional framework, making it difficult to transfer mechanisms
successfully from one country context to another.
Drawing the strands together: primary care in perspective 73
Changing quality standards
The two final chapters (Chapters Eleven and Twelve) focus on continuous quality improvement in primary care. Both chapters underscore the importance
of encouraging ongoing processes of quality enhancement while recognizing
that, particularly with new technology, new challenges also will need to be
addressed.
Baker et al. in their chapter “Improving the quality and performance of
primary care” detail the large number of ongoing quality improvement programmes in primary care across Europe (Chapter Eleven). Looking forward, they
emphasize the importance of moving quality improvement programmes to a
second stage that incorporates patients. This is not easy to achieve and as yet
there is insufficient evidence to indicate that this second, shared stage is more
effective. The authors also suggest that national programmes should promote a
culture that emphasizes GPs’ sense of self-esteem as a way to help make quality
improvement a normal part of GPs’ daily work routine.
Kvist and Kidd (Chapter Twelve) take a similarly hortatory perspective in their
chapter on new information and communication technologies. They
emphasize that primary care practitioners will need to keep up with patient
expectations regarding the Internet and e-mail. Further, GPs will find that integrating these new information technologies can help improve quality in such
areas as antibiotic prescriptions, drug dosing, and preventive care. However, the
authors caution that GPs will have to be alert to new challenges reflecting problems relating to quality control of information (particularly on the Internet) as
well as liability issues.
In sum
Taken overall, the eight co-authored expert chapters paint a picture of substantial innovation and change in primary care systems. The portrait that
emerges from these chapters is one of growing complexity – in the content of
primary care services, in its organizational structure, in its relationships (both
formal and informal) with other sectors of the health care system, in its range
of personnel and in the responsibilities that it assumes. This new level of complexity requires a substantially different level of managerial coordination than
did the earlier, traditional model of primary care based on single-GP offices. A
second observation is that, with regard to primary care as elsewhere in the
health sector, context matters. In this case the importance of context can be
seen in the varying scope of work that primary care personnel are expected to
perform, in primary care relationships both upward with specialist hospital care
and downward with other components of primary health care, and, lastly, in
the impact of a diverse set of broader societal trends ranging from consumer
involvement to electronic recordkeeping. A third observation is that the
ongoing process of change in primary care does not point toward any single
dominant organizational and/or behavioural framework.
Given the degree of change in primary care seen to date, it may be useful to
provide a brief review of the organizational distance it has already come, and of
74 Primary care in the driver’s seat?
the policy challenges that remain to be addressed. These two assessments
then lead directly into a discussion about the specific role that primary care
might appropriately play in the future leadership of the health care system –
e.g. whether and/or to what degree primary care ought to be in the “driver’s
seat”.
Primary care’s accomplishments thus far
From an organizational perspective, primary care has undergone dramatic
development over the past 30 years. At the beginning of the 1970s, most primary care in Europe was delivered in one of two geographically defined but
broadly consistent manners. In western Europe, it was provided overwhelmingly in single-GP private practices and was almost exclusively curative in focus.
In central and eastern Europe, the transition to the Semashko model had been
largely completed with first contact care – also curative in focus – provided
predominantly by specialist physicians in ambulatory polyclinics. In this
traditional picture, primary care clearly sat at the periphery of the overall health
care system, with specialist hospital care and the issues associated with secondary and tertiary level curative care dominating the centre of both health
policy-making and health service delivery.
The first broadly systematic change in this picture came in Finland with the
passing of the 1972 Primary Health Care Act. This required municipal authorities to provide preventive as well as curative primary care services to their
inhabitants, and folded these services into broader primary health care centres,
which combined primary care physicians, nurses, social workers, and health
educators into a comprehensive team (Järvelin, 2002). Sweden adopted a similar
primary health centre based strategy with its 1973 Primary Health Care Act
(Hjortsberg and Ghatnekar, 2001). This Nordic initiative was soon followed by
the global approach taken by the Alma Ata Declaration of 1978, which
emphasized the centrality of primary health care to the operation of effective,
efficient and equitable health services, particularly in developing country contexts (World Health Organization, 1978). Thus by the end of the 1970s, one
could see the first cracks in the traditional GP-based model: the organizational
framework for the delivery of primary care, the exclusive focus on curative
medical treatment, and the role of general practitioners as solo practitioners had
all for the first time come under principled conceptual and practical challenge,
not just concerning developing countries but within the Nordic region in
Europe as well.
The 1980s brought a wide range of initiatives that built upon the concept of
primary health care, and the role of primary care as delivered within primary
health centres. By the mid-1980s Sweden had articulated its primary health
centre based system, and Finland was doing so as well. Countries like Greece,
Netherlands, Spain, and also the United Kingdom, were developing a number of
similar publicly operated, comprehensive centres. Symbolizing both the shift in
policy-making emphasis and the growing hegemonic aspirations of the primary
health care movement, WHO’s Regional Office for Europe sponsored an “action
research” project across a half-dozen countries that sought, as its name suggests,
Drawing the strands together: primary care in perspective 75
to “Tip the Balance Toward Primary Health Care”. This project subsequently
published a volume of research in 1995 (Rathwell et al., 1995).
During this period there was arguably less change in the delivery of primary
care services in the Social Health Insurance (SHI) countries of western Europe.
Despite experiments with better coordination between GPs and hospital and/or
other primary health care providers, as well as the emergence of some group-like
responses to cover problem areas such as providing out-of-hours coverage, the
vast majority of primary care continued to be delivered by solo practitioners
(Boerma and Fleming, 1998).
The 1990s generated a dramatic upsurge in organizational change in primary
care in both western and central Europe. As several chapters in this volume
document, the solo GP in countries like the Netherlands and, to a lesser extent,
Belgium became increasingly caught up in various voluntary network-like
arrangements, coordinating services both with other primary health care providers and with some hospital clinics. In the United Kingdom’s tax-based system, April 1991 brought the first wave of GP fundholders, transforming GPs
into budget holders for a portion of their patients’ elective hospital procedures
(Glendinning and Dowling, 2003). Despite concerns about the “state agent”
aspect of this new financial role, fundholding spread into a variety of more
extensive models, including “total fundholding,” which, in turn, became a
model for the Primary Care Groups that were introduced in April 1999.
In central Europe, the 1990s were a period of major transformation in health
care generally, and in primary care in particular (McKee et al., 2004). Abandoning the Semashko model, state-run polyclinics were dismantled and replaced by
private GPs. In the former East Germany, the West German model of independent solo and/or group practice was replicated. Countries like Estonia and Latvia
established training programmes in primary care in their medical schools, providing specialists with six months retraining before they began new practices as
GPs. Thus, after starting the decade with an almost entirely state-employed
polyclinic approach to first contact medical care, many of the central European
countries ended the 1990s with a largely private cadre of general practitioners
(see Chapter Seven, Sheaff et al.).
The 1990s generated substantially less change in primary care in the SHI
countries of western Europe, perhaps due to that system’s highly articulated
status (in Germany and the Netherlands) or the controlling role of le médécin
liberal (in France). However, various experiments with networks of GPs were
organized in the Germany, Netherlands, and in Switzerland, and, as detailed
above by Sheaff et al. (Chapter Seven), a wide range of new activities appeared in
such areas as coordinated care for the chronically ill and the elderly. While the
rate and scope of change was considerably less than in tax-funded western
Europe and dramatically less than in central European countries, nonetheless
measurable change appeared to be under way.
When one steps back and reviews the overall process of change over the
30-year period since the Finnish Primary Health Care Act, one cannot help but
be impressed with the remarkable growth and development that has taken place
in the organizational structure, the capacities and range of personnel, the
budgetary impact, and, perhaps most importantly, the policy legitimacy of primary care. It is a sector of European health care systems which began this period
76 Primary care in the driver’s seat?
very much at the periphery, but which is now struggling to be taken seriously at
the very centre of these systems. One of the most important aspects of this shift
has been that in a number of countries primary care is now no longer viewed as
completely overshadowed by and subordinate to hospital level care. Rather, it
has begun the long and complex process of establishing itself as an equally
legitimate partner of the secondary and tertiary care sectors. The wide range
of experimentation currently under way, the broad diversity of new models
and approaches – clinical, managerial, and financial – all speak to the accomplishments achieved by primary care to date, and bode well for its future.
Continuing challenges
Notwithstanding the recent accomplishments of primary care across Europe,
there still remains a wide variety of organizational challenges that have yet to be
adequately addressed. Based on the assessment presented in the preceeding
chapters, it would appear that some of these challenges represent the fruits of
primary care’s considerable development to date, while others are longstanding dilemmas that have yet to be resolved. Viewed from a comparative
European perspective, these challenges can usefully be grouped into three general topics. The first can be termed ‘managing the network’, a challenge which
has both clinical and financial dimensions to it. The second challenge can be
termed the ‘credibility question’, which involves the ability of primary care in
general and GPs in particular to maintain and/or obtain the necessary respect
and status to support further progress and development inside the health care
system. The third challenge involves integrating information technology and
electronic recordkeeping into GPs’ offices and daily routines, especially patient
consultations. Each of these three main challenges will be discussed in turn.
Managing the network
Perhaps the central development in the organization of primary care in western
Europe over the past 10 to 15 years has been the growing role of networks. As
discussed at length in Calnan et al. (Chapter Five), Sheaff et al. (Chapter Seven),
and Heyrman et al. (Chapter Nine), a broad and diverse range of networks has
emerged to help manage clinical services. In response to increases in the number of chronic care patients, as well as the improved technical capabilities of
telecommunications and electronic technologies, GPs are finding themselves
involved in three levels of patient care generated networks: upward to secondary and tertiary level hospital care (for care of specific conditions, for example
diabetes or asthma); laterally with other elements of primary care (for example
for community nursing and out-of-hours coverage); and downward with public
health and basic health care services (for example school health care and occupational health services). As Calnan et al. noted (Chapter Five), the new GP
coordinating role no longer looks like gatekeeping, with its single port of entry
and its mandatory control over patient referral to specialist care. Rather, a form
of “differentiated gatekeeping” appears to be emerging, in which chronically ill
Drawing the strands together: primary care in perspective 77
patients can elect to have a specialist as their main caregiver, while other
patients can rely on the GP more as an advisor when they need to cross sectoral
borders within the health care system, possibly in a voluntary rather than a
mandatory gatekeeping arrangement. Although the type of physicians acting
as gatekeepers would be expanded, in this new approach the list system remains
in place, given its essential role in coordinating care and keeping patient
information in a single location. This model may be more suited to those SHI
countries which have previously had open access to specialist care, as highlighted by the differentiated structure of the new 2005 universal gatekeeping
programme in France (although the new French arrangement is mandatory
not voluntary in design). A more flexible approach may become more appropriate in the future in countries like the Netherlands, however, where the growth
of networks is substantial as is a vocal patient empowerment movement (Wildner
et al., 2004). More generally, it may well be that gatekeeping will evolve
differently in different national settings, with varying mixes of characteristics.
The issue of financial responsibility inside these new networks – or indeed for
care delivered elsewhere in the health care system – raises a host of additional
challenges for GPs. Beyond responsibility for managing patients’ clinical pathways – in networks as previously in gatekeeping arrangements – the financial
dimension requires GPs and/or primary care to take on further managerial roles
vis-à-vis other providers in the health care system. McCallum et al. (Chapter
Three) present a variety of arrangements in which GPs and/or primary care are
budget-holders for some combination of services beyond just clinical primary
care in their offices. However, if GPs individually (or general practice as a discipline) increasingly take on financial management responsibilities for care
delivered elsewhere, particularly in hospitals, they are confronted with what
can be termed the “state agent” problem (Saltman, 2005). Since most of the
funds being managed are either publicly raised or publicly supervised, GPs
either directly (themselves) or indirectly (through the decisions of other managers in their practice or in primary care) may find they are placed under growing pressure to contain costs even if such reductions would require trimming
back necessary patient care (Ham and Honigsbaum, 1998). Here, the concern is
the potential risk to the GPs’ fundamental role as the representative of the best
interest of the patient. A corollary aspect of this state-agent dilemma is the
potential reduction in patient trust in his/her GP to make clinically appropriate
decisions (Calnan and Sanford, 2003) – a situation which turned out to have
serious long-term consequences when it was created by the admittedly different
managed care arrangements found in the 1990s in the United States (Robinson,
2000).
As primary care looks forward, the twin challenges presented by both clinical
and financial management of emerging network arrangements will become
increasingly important. There are likely to be a variety of different solutions
pursued, reflecting different arrangements for primary care across different
countries (as highlighted in Chapter Two) as well as the range of different
national cultures and social values that will necessarily come into play here as
with restructuring in any health sector institution (Saltman and Bergman,
2005).
78
Primary care in the driver’s seat?
The credibility question
As suggested by the discussion about the state-agent issue just above, patient
trust is an essential dimension of effective primary care practice. While recent
research indicates that GPs in well-developed western European health systems
such as Netherlands and Sweden receive high ratings from patients (Socialstyrelsen, 2002; Van der Schee et al., 2003), they appear to lack the same levels of
status and credibility of most of their specialist counterparts (Saltman, 2005).
While some primary care experts do not see this as a serious problem, it would
seem clear that GPs require adequate credibility with both medical specialists
and with patients if they are to successfully manage the types of complex crossborder networks that are now emerging in a number of health care systems. The
question of trust, respect, and status – summarized in the notion of credibility –
is likely to require considerable attention in the future from advocates of
increased primary care responsibility in the wider health system (Saltman,
2005).
Information technology
This would appear to be the least daunting of the likely future challenges, in
that it appears to be ‘only’ a technical issue. In reality, as both Kvist and Kidd
(Chapter Nine) and also Baker et al. (Chapter Eight) indicate, the process of
integrating electronic technologies into primary care practice will involve a
wide range of organizational and procedural challenges, including the ability to
maintain patient privacy and confidentiality. It carries a range of implications
for present and future professional behaviour as well. The introduction of full
electronic records involves nearly every aspect of primary care and has the
potential to improve and/or systematize a large number of GP decisions and
activities. It also introduces the possibility of considerably more thorough
external monitoring and evaluation of primary care services – a controversial
issue for many GPs.
The driver’s seat question
In previous sections, this chapter has sought to construct a broader organizational and comparative context in which to place the ongoing changes in primary care across Europe. Taken together, the preceding sections of this chapter
serve to frame the main question contained in the volume’s title, which has
been a central question in the health policy debate for some 20 years. Namely, is
primary care capable of taking a dominant role in running the whole health care
system, and, second, if it is sufficiently capable, would it be wise to do so? An
adequate consideration of these questions involves a number of related
elements, many of which are raised either directly or indirectly in the Part Two
chapters. One major issue involves the direction that primary care itself is
taking in its own development – away from solo practice toward networks
and other forms of coordination – as well as the pressing need mentioned by
Drawing the strands together: primary care in perspective 79
Calnan et al. (Chapter Five) to consider alternative strategies to re-develop the
concept of gatekeeping. Can primary care successfully pursue these next stages
in its own evolution while at the same time taking on not just the clinical
coordinating responsibilities for the evolving system of primary care and crossborder networks (as is evolving in the Netherlands) but also planning and
financial responsibility for other health care providers as well (a model currently
under construction as Primary Care Trusts in England)?
A wide range of questions and concerns arise in response to this potential new
role for primary care generally and for GPs and general practice in particular.
One wonders, for example, how giving general practice a greater ‘state-agent’
role across the entire health care system will affect the time GPs have to treat
patients, and the trust with which they (and their medical advice) is viewed by
patients. If a mix of general practitioner and/or general practice does take the
driver’s seat, clearly more time will need to be spent on coordination and stateagent functions. Who within general practice – or primary care more broadly –
fulfils these administrative and managerial responsibilities then becomes a
central question. If GPs specifically are expected to spend their time meeting
these organizational needs, it is likely to decrease the time available to be providers of patient care. On the one hand, in terms of their overall credibility, this
new financial and administrative role would clearly increase GPs power vis-à-vis
hospital specialists and other primary care providers. Yet if GP power increases,
there can be little certainty that it will increase their status, respect, or authority
– which requires the legitimating assent of patients, specialists, and policymakers (Weber, 1947; Pfeffer, 1981). It is equally difficult to be certain how it
will affect the trust they are granted from patients (Saltman, 2005).
Coupled to these perspectives regarding power and credibility are the realities
of what GPs themselves prefer. GPs often mention that they are trained to take
care of patients, not to administer health care budgets. Some commentators
have suggested that while a small group of GPs might be interested in an
enhanced managerial role, the majority would prefer to simply treat patients.
One potential alternative to putting GPs and/or general practice in the
driver’s seat would be to put primary care as an organization in the driver’s seat,
with the GP in the back seat, so to speak. This would entail developing managerial capacity inside primary care, with the GP serving as an advisor to its exercise,
but without tangling up GPs directly in financial contracts concerning providers
elsewhere in the health care system. Examples already exist of giving this
responsibility to public representatives of elected bodies in Sweden, where
subcounty-level political boards (e.g. at district level inside Stockholm County)
administer much of the hospital budget (Hjortsberg and Ghatnekar, 2001), and
in Finland, where municipal health and social boards play much the same role
(Järvelin, 2002). A third variant is the Primary Care Trusts (PCTs), which are
taking on the contracting responsibilities once held either by fundholding GPs
or by the now-defunct District Health Authorities (Bindman et al., 2001).
One should note that all three of these variants have developed in tax-funded
health systems – thus far an example of a similar managerial role for primary
care has yet to emerge within social health insurance systems (Saltman et al.,
2004). A 1993 Dutch futures study suggested three possible alternative ways to
provide coordinated primary care in an SHI system, based on, respectively,
80 Primary care in the driver’s seat?
larger primary care units (such as primary health care centres), hospitals providing primary care, or an integrated home care organization providing primary
care (Steering Committee on Future Health Scenarios, 1993). More than 10
years after this study, the future organizational structure for delivering
primary care in the Netherlands or other SHI countries remains quite diverse
and rather unsuited to taking up a driver’s position. One possibility is that
sickness funds may establish stricter requirements in their contracts with
primary care providers concerning, for example, quality, coordination, and
range of services, and thereby help to push primary care towards a broader
organizational role.
How various primary care led models might develop in the future is contingent on a number of imponderables. Perhaps the most fundamental issue is
whether emerging primary care approaches can develop a good working balance between the managerial needs of the health system and the practical
service delivery concerns of providers. If growing coordination and state-agent
functions are to be transferred to these primary care organizations, it will be
essential to ensure that they develop methods of working that harmonize with –
rather than disrupt – GPs’ ability to provide appropriate clinical care to their
patients. It may well be that these GP/Primary Care Manager balances will
develop differently within different countries (or even within different parts of
the same country, as the Dutch scenario study foresaw), dependent on a range
of institutional and cultural considerations. How these new balances evolve is
likely to be essential in determining their longevity. In the long run, it is possible that new GP/Primary Care Manager arrangements could form the basis for
an as yet undefined new paradigm which might eventually emerge in primary
care in Europe.
Notes
1
2
Prior versions of this chapter were presented in the John Fry Lecture of the Nuffield
Trust, London; and at seminars in Lisbon, Almaty, CREDES, and at the London School
of Economics. The current version benefits considerably from comments made by
participants at these previous presentations and by Wienke Boerma.
Support for this section was provided by Hans Dubois.
References
Bindman, A.B., Weiner, J.P. and Majeed, A. (2001). Primary care groups in the UK: quality
and accountability, Health Affairs, 20(3): 132–145.
Boerma, W.G.W. (2003). Profiles of General Practice in Europe. Utrecht: NIVEL.
Boerma, W.G.W. and Fleming, D.M. (1998). The Role of General Practice in Primary
Health Care. Copenhagen: WHO Regional Office for Europe.
Boerma, W.G.W., Van der Zee, J. and Fleming, D.M. (1997). Service profiles of general
practitioners in Europe, British Journal of General Practice 47: 481–486.
Calnan, M. (2002). Comment at author’s workshop, 22 May, London.
Calnan, M. and Sanford, E. (2003). Public Trust in Health Care in England and Wales. The
System or the Doctor? Bristol: University of Bristol.
Drawing the strands together: primary care in perspective 81
Dowling, B. and Glendinning, C. (eds) (2003). The New Primary Care: Modern, Dependable,
Successful? London: Open University Press/McGraw-Hill.
Glendinning, C. and Dowling, B. (2003). Introduction: “Modernizing” the NHS, in
Dowling, B. and Glendinning, C. (eds) The New Primary Care. Modern, Dependable,
Successful? Maidenhead: Open University Press.
Goicoechea, J. (ed.) (1996). Primary Health Care Reforms. Copenhagen: World Health
Organization.
Ham, C. and Honigsbaum, F. (1998). Priority setting and rationing health services, in
Saltman, R.B., Figueras, J. and Sakellarides, C. (eds) Critical Challenges for Health Care
Reform in Europe. London: Open University Press.
Hjortsberg, C. and Ghatnekar, O. (2001). Health Care Systems in Transition: Sweden.
Brussels: European Observatory on Health Systems and Policies.
Järvelin, J. (2002). Health Care Systems in Transition: Finland. Brussels: European Observatory on Health Systems and Policies.
Kark, S.L. (1981). The Practice of Community-Oriented Primary Health Care. New York:
Appleton-Century-Crofts.
Marshall, M., Campbell, S., Hacker, J. and Roland, M. (2002). Quality Indicators for General
Practice: A Practical Guide for Health Professionals and Managers. London: Royal Society
of Medicine Press.
McKee, M., MacLehose, L., and Nolte, E. (eds) (2004). Health Policy and European Union
Enlargement. Berkshire: Open University Press/McGraw-Hill.
Peckham, S. and Exworthy, M. (2003). Primary Care in the UK. Basingstoke: Palgrave
Macmillan.
Pfeffer, J. (1981). Power in Organizations. Marshfield: Pitman Publishing.
Rathwell, T., Godinho, J. and Gott, M. (eds) (1995). Tipping the Balance Towards Primary
Health Care. Avebury: Ashgate Publishing.
Robinson, R. (2000). Managed health care: a dilemma for evidence-based policy, Health
Economics 9(1): 1–7.
Saltman, R.B. (2005). Primary Care in the Driver’s Seat? John Fry Lecture. London: Nuffield
Trust.
Saltman, R.B., Busse, R., and Figueras, J. (eds) (2004). Social Health Insurance Systems in
Western Europe. Berkshire: Open University Press/McGraw-Hill.
Saltman, R.B. and Bergman, S-E. (2005). Renovating the commons: Swedish health
care reforms in perspective, Journal of Health Politics, Policy and Law 30(1–2):
253–275.
Socialstyrelsen (2002). Komma fram och känna förtroende. – Befolkningens syn på tillgänglighet och fast läkarkontakt i primärvård [Reaching the services and feeling confidence – The
view of the population on availability /accessibility continuing relationship with a doctor].
Stockholm: Socialstyrelsen.
Starfield, B. (1998). Primary Care: Balancing Health Needs, Services, and Technology. Oxford:
Oxford University Press.
Steering Committee on Future Health Scenarios (1993). Primary Care and Home Care
Scenarios 1990–2005. Dordrecht: Kluwer Academic Publishers.
Van Zwanenberg, T. and Harrison, J. (eds) (2000). Clinical Governance in Primary Care.
Abingdon: Radcliffe Medical Press.
Van der Schee, E., Braun, B., Calnan, M., Schnee, M. and Groenewegen, P.P. (2003). Public
trust in health care: a comparison of Germany, the Netherlands, and England and
Wales. Presentation at the European Public Health Association conference in Rome,
20–22 November.
Weber, M. (1947). The Theory of Social and Economic Organization. New York: Oxford
University Press.
Wildner, M., Den Exter, A.P. and van der Kraan, W.G.M. (2004). The changing role of the
82 Primary care in the driver’s seat?
individual in social health insurance systems, in Saltman, R.B., Busse, R. and Figueras,
J. (eds) Social Health Insurance Systems in Western Europe. Berkshire: Open University
Press/McGraw-Hill.
World Health Organization (1978). Declaration of Alma-Ata. International Conference on
Primary Health Care: Alma-Ata, 6–12 September 1978. (http://www.who.int/hpr/
NPH/docs/declaration_almaata.pdf, accessed 16 March 2004).
part
two
Changing institutional
arrangements 83
Changing working
arrangements 147
Changing quality standards 201
chapter
five
The challenge of
coordination: the role of
primary care professionals in
promoting integration across
the interface
Michael Calnan, Jack Hutten and
Hrvoje Tiljak
The problem of coordination
The issue of integration and coordination in health care is not new. For many
years problems concerning separation and fragmentation of services as well as a
lack of communication (Grundmeyer, 1996) and cooperation between health
care providers have been discussed in many European countries. However, due
to changes in the demands and needs of the population, the search for solutions
has become more urgent. The aging of populations leads to an increase in morbidity, especially in the incidence and prevalence of chronic conditions as well
as comorbidity. This may lead to a higher demand for health service in general
and for more complex, multidisciplinary care in particular. More and different
combinations of health services will increasingly be required. Patients who are
being treated by more than one care provider are particularly vulnerable to the
adverse consequences of inadequate coordination and communication.
Certainly, from the patients’ point of view, the integration of care is a crucial
element in their evaluation of the quality of care. For example, a study in
the United Kingdom (Preston et al., 1999) showed that patients and carers identified five specific issues involved in their experiences across the interface
between primary and secondary health care. Four key dimensions were “getting
in” (access to appropriate care), “fitting in” (orientation of care to their
86 Primary care in the driver’s seat?
requirements), “knowing what’s going on” (provision of information), and
“continuity” (continuity of staff and coordination and communication among
professionals). The fifth theme was “limbs” (difficulty in making progress
through the system), which was influenced by failures in relation to the other
four themes. The concept of progress is central to patients’ views of care. It
involves both progress through the health care system and progress towards
recovery or adjustment to an altered state. It is suggested that the concept of
progress may be an appropriate indicator for monitoring health service
performance.
The call for increased “patient empowerment” and personalization of care
may also have an impact on the need for coordination (Roberts, 1999). A fundamental shift may be required from a service-oriented health care system (“the
availability of services to define the kind of care that is provided”) towards a
more patient-centred approach (“the actual needs of the patient define the kind
of care that is provided”). This implies that the provision of care should be
organized around and tailored to patients’ needs, which requires specific
coordinating activities. In addition, the setting in which health care is delivered
is changing (from institutional care towards ambulatory care) which may also
have implications for the need for coordination of services. This development is
enhanced by the introduction of new technologies, especially those that can be
used in an ambulatory setting, which means that more severe cases can be cared
for at home.
The need, therefore, for enhanced coordination and integration of care is
becoming increasingly important. This chapter focuses on the organizational
mechanisms that can enhance the role of primary care in coordinating and
integrating care. It will be divided into two sections. The first part of the chapter
focuses on how the problem of integration (or the lack of it) and coordination
manifests itself in different European countries, whether it tends to be associated with certain types of health care systems – NHS model (the United Kingdom), Social Insurance (France, the Netherlands) and Transitional System
(Croatia) – and whether it is associated with specific organizational structures,
such as the presence of a gatekeeping system. This includes a discussion of the
problems of coordination and where they are most evident. The second section
deals with solutions the different case study countries (illustrating the different
health care systems) have adopted and what benefits the specific solutions have
brought, if any.
How do problems associated with coordination manifest
themselves in different health care systems?
One important way of characterizing a health care system is to examine whether
general practice has a strong central position or not. This organizational feature
has numerous implications for the issue of coordination.
The challenge of coordination: the role of primary care professionals
87
Problems with gatekeeping
In countries such as Denmark, the Netherlands and the United Kingdom, GPs
have a central position in the health care system. This is mainly based on their
role as “gatekeepers”. All members of the public (except 5% in Track II in
Denmark) are registered with a general practice, the so-called personal list system. The GP is usually the first professional confronted with the patients’ problems and the first to decide which kind of services are required. Most drugs are
provided only by prescription and often other care providers, such as medical
specialists, are accessible only after a referral by a GP. Gatekeepers intend, when
possible, to treat patients themselves as long as possible and refer their patients
to specialist care only when it is really needed. Furthermore, gatekeepers act
as patients’ guides through the health care system to ensure that they receive
the kind of care that is appropriate. This role of the gatekeeper has been defined
as providing navigation and enhancing responsiveness. Their central position
enables them to keep medical records of the patients and thus enhance
continuity of care.
To sum up, two gatekeeping roles can be identified. First, their control of the
use of specialist, hospital or other expensive services, is meant to reduce or
restrict health care costs, i.e., GPs act as a mechanism for rationing services.
Secondly, they are expected to improve or maintain quality of care through
their coordinating role. In this way, GPs are considered as the coordinators of
the whole packages of care that is received by a patient, which could improve
continuity. Thus, gatekeeping can be seen in a negative light as a mechanism for
restricting access to otherwise beneficial care and cutting costs at the expense of
the patient. Yet the safety of health care requires that only appropriate care is
prescribed and that the system is able to respond to specific individual needs.
Therefore gatekeeping can be seen, at least in theory, as an organizational
mechanism to promote integration, although problems can exist in implementing this mechanism (see below). Some studies provide evidence of the effectiveness of gatekeeping (Starfield, 1991; Gervas et al., 1994; Shi et al., 1999; Delnoij
et al., 2000; Gross et al., 2000). However, according to Halm et al. (1997) it is still
largely unproven whether gatekeeping achieves the dual goals of restricting
health care costs and enhancing quality of care.
In the United Kingdom in the NHS system, the principal focus has been on
problems of coordination across the primary/secondary care (hospital) interface, particularly poor communication due to professional rivalry between hospital doctors and GPs. There has been a continual problem of fragmentation
between primary care, community services and social care owing to different
systems of governance (Glendenning et al., 1998). This latter problem has only
recently been addressed with the introduction of Primary Care Groups (PCGs)
and Primary Care Trusts (PCTs) in the United Kingdom.
Problems of communication between care providers are also prevalent in the
Netherlands. They result in problems in patient education (patients receive different kind of information), discontinuity in care (waiting times and a lack of a
“smooth stream” of patients through the health care system), less efficient use
of resources in the provision of care (care providers do not know what diagnostic tests or treatments have already been performed by others, so they repeat
88 Primary care in the driver’s seat?
them). Several causes for these problems can be identified. One is the organizational boundary between (generalist) primary and (specialist) secondary care
Furthermore, the two core disciplines of primary care – general practice and
home care – are organized and financed separately. These boundaries are now
the main obstacles to the provision of integrated care tailored to the needs of
individual patients (see De Roo et al., 2004).
An additional problem is the broad range of tasks that GPs perform (Moll van
Charante et al., 2002). It includes preventive activities, acute curative care, care
for patients with chronic conditions and sometimes emergency care (out of
office). It is difficult to coordinate all these tasks inside and outside the general
practice, especially with an average list size of 2 250 patients. A study in the
Netherlands showed that the workload of GPs influences the kind of care they
provide in daily practice (Hutten, 1998). Busy GPs have shorter consultations
with individual patients, carry out fewer technical medical interventions (injections, minor surgery), prescribe medication more often and have higher referral
rates to other primary care providers (mainly physiotherapists) than less busy
GPs. Furthermore, coordinating activities requires time that is not always available due to high patient loads, more administrative tasks, more time required
for continuous medical education and the tendency to work in part-time jobs.
Therefore, workload is considered a threat to the position of GPs as gatekeepers
in the Dutch health care system.
Problems in non-gatekeeping countries
In other systems general practice has not played such a central role. For
example, in the French health care system patients have traditionally had a
choice of provider. For ambulatory care, they could visit a GP or a specialist
without referral or limitation, either in private practice or in outpatient departments in hospitals. If a physician prescribed tests or care to be performed by
another professional, patients could choose the laboratory, nurse or physiotherapist. Although there had been no compulsory registration with a GP,
people did have a preferred GP and were generally loyal to their GP with little
evidence of “shopping around”. There were, however, variations in consulting
patterns of care according to social status, with the upper classes tending to
favour specialist care, while manual workers preferred to consult a GP.
The lack of such an organizational mechanism in the French system produced
problems of coordination and particularly in continuity of care, which was a
source of dissatisfaction. This was due to patients having to organize their own
journey through the health care system. No professional had formal responsibility for the process of care provided to an individual and the maintenance of his
or her health. Moreover, it had become increasingly difficult for GPs to take this
role with the development of numerous, highly specialized health care suppliers
directly used by patients. Now that the French government has adopted compulsory universal gatekeeping as of 1 January 2005, it remains to be seen
whether this new programme will adequately resolve these dilemmas.
There are objective data that indicate that lack of coordination in France can
have a negative impact on the quality of care. For example, a national study
The challenge of coordination: the role of primary care professionals
89
conducted by the main sickness fund has shown that the medical guidelines for
diabetes issued by the National Agency for Evaluation and Accreditation were
only partly respected. Only 40% of diabetes patients have an eye examination
once a year, with the same percentage having a biological follow-up every
six months as recommended. Part of the problem may come from inadequate
individual practices; however, the process of care is not managed by the system.
It may be that the physician prescribes the tests correctly and advises his or her
patient to see an ophthalmologist (and a chiropodist), but that the patient fails
to follow this advice. The physician is not in a position to monitor the compliance of his or her patient, however, who may be seeing other physicians for the
same illness.
There is growing concern in France that chronic illnesses, involving a process
of care necessitating contacts with different professionals in the health care
system, are not always adequately managed. In addition to national policies on
diseases like diabetes and hypertension, the regional unions of sickness funds
carry out surveys on various chronic conditions to evaluate the quality of outpatient care and undertake actions to improve medical practice. The lack of
coordination is also a problem in two classic situations: the interface between
hospital care and ambulatory care and the interface between health care and
social care. As mentioned, it remains to be seen if the current reforms will
positively affect these problems.
In central and eastern European (CEE) countries, the importance of one type
of practitioner is also less prevalent. Instead, common practice has involved a
shift towards dispanseurs – specialized clinics for specific health problems. In the
late 1980s, before democratization, this approach resulted in two basic types of
Primary Health Care (PHC) settings. One is known as ‘home of health’ or PHC
centres, which could correspond to group practice in western European countries. These centres mainly consisted of a group of PHC professionals: GPs and
other PHC specialists (paediatricians, gynaecologists), as well as other specialist:
internists, oculists, dermatologists, etc. In the former Soviet Union, three PHC
practitioners served as the basic PHC structure of so-called ‘threeplets’. Their
education would be similar to education of internists, paediatricians and gynaecologists, but they worked together as a basic team responsible for PHC service.
A slightly different system was created in ex-Yugoslav countries, where GPs
were recognized as basic PHC practitioners. Most of them worked in PHC
centres together with other specialists and they played a gatekeeping role
within that context. The GPs role included a personal list of patients, keeping an
individual medical records of those patients and other administrative
responsibilities.
These structures prevented PHC practitioners from becoming individual
practitioners offering personal care. Instead, the public perception of PHC
practitioners was quite low.
The 1990s transition in CEE countries was characterized by two parallel pathways: (1) recognizing PHC practitioners, mainly as GPs, as a basic element of
the PHC service; and (2) privatization of health care. Both movements led to
the disintegration of the existing PHC structure and put the GP in a new situation. The GP became the symbol of PHC overall in the professional, medical
perspective and at the same time the GP became a private entrepreneur. The
90 Primary care in the driver’s seat?
coordination role became more evident, but at the same time GPs were allocated
important new tasks. Moreover, the coordination role was strongly related to
other tasks: financial and organizational, professional development, obligations
derived from contractual commitments, and medical educational preference.
The structure of these new PHC settings suggests a broad collaboration, a great
amount of teamwork and consequently a need for coordination. However, in
the absence of a basic medical professional, the role of coordination was usually
allocated to the health care manager or the local health care authority. These
managers/co-coordinators were not always medical professionals. This system
developed a paradoxical situation in which a group of PHC practitioners worked
together but did not collaborate and coordinate their work.
Hospital doctors and consultants gained more public respect. Although the
system encouraged good PHC/hospital interface (consultants were working in
PHC centres), problems in collaboration emerged from the constant struggle for
task allocation and the prolonged battle for public appreciation.
In sum, we can conclude that each of these different systems of organization
presents distinct barriers to coordination, as well as a common failure to implement traditional communication channels. The literature suggests that the traditional structural barriers to coordinated care can be characterized in terms of
separate management and governance (health and social care are in different
parts of the public sectors); different ownership (public/private); atomized and
competing providers; professional barriers (rivalries within and between professional groups); and also the problems involved in the implementation and
operationalization of coordination instruments (such as delays in referral
letters, completeness of patient records and communication between teams).
How different countries have dealt with coordination
(country case studies)
The previous section distinguishes between countries with and without gatekeeping systems. However, as will be seen, each of the different countries has in
some respects developed different strategies and solutions.
The French experience
There is a long history in France of local initiatives from health professionals to
improve coordination among them. Networks were, for instance, organized at
the end of the 1980s between hospital physicians and GPs for patients with
AIDS. This coordination was particularly necessary since most treatments were
initiated or provided in hospitals, and the GPs had to stay in close contact with
hospitals in order to treat the patient effectively. Networks were also implemented spontaneously, using the same model, for specific populations, such as
drug addicts, people suffering from hepatitis C, and very poor people. The physicians involved were generally GPs with strong social and/or political commitment. The Ministry of Health encouraged these networks with grants, but they
were basically functioning according to the general rules for the delivery and
The challenge of coordination: the role of primary care professionals
91
financing of health care. The idea of giving one physician the responsibility of
managing the care for a patient with a chronic condition (‘referring physician’)
was first envisioned in 1993. At that time, the idea was that it could be either a
GP or a specialist, according to the condition and the choice of the patient. This
was not implemented at that time, but it was decided that for patients that had
serious illnesses which exempted them from co-payments, the physician
advisor of the sickness fund should validate a protocol of treatment in agreement
with the physician following the patient.
The same reform implemented the carnet de santé: the idea was that patients
would have a personal health record, which they would show to every physician
or health professional consulted, who in turn would update it. The measure was
first implemented for the elderly, then extended to the whole population by the
1996 Juppé reform (discussed below).
This regulatory instrument suffered from a double logic and somewhat contradictory objectives. It was an instrument of coordination, but with the primary aim of reducing useless expenses (by eliminating redundant tests and
procedures and preventing health care consumers from irresponsible
behaviour) rather than with the aim of improving quality.
Presented that way, this measure was more a constraint to patients than a
benefit. If the health record had to be shown to all the physicians that a patient
was going to see, it would have been difficult, for instance, to consult with a
specialist without informing the GP, or to seek a second opinion. Since it was
not compulsory (i.e., patients were reimbursed in any case), it did not work.1
The 1996 Juppé reform opened up a new opportunity by allowing separate
agreements with GPs on the one hand, and specialists on the other. Until then
there was a single agreement – the medical profession had always been very
careful not to let the government divide them (Wilsford, 1991). A separate negotiation was the benefit given to what was, at that time, the main union of GPs
(MG-France), for their support to the 1996 reform.2 This union promoted a
specific re-evaluation of the status of the GP in relation to the specialist, and in
1997 signed an agreement introducing the possibility, for any patient, to choose
a ‘referring GP’.
In this system (optional for both patients and doctors), GPs who agree to be a
referring physician accept commitments: they are paid directly by sickness
funds and not by the patient, they keep the patient’s medical record, provide
continuous service, ensure continuity of treatment, participate in public preventive programmes, follow the recommendations on good practice, and prescribe a certain percentage of generic drugs, etc. In return, for each patient
enrolled, the physician receives an annual payment, which was doubled in 2000
to promote the scheme (currently 46 euros, which is fairly generous compared
to the average annual fees per patient).
Under this plan the patient is encouraged to consult their GP first (except in
emergencies), to consult a specialist only with GP referral, to bring the health
record to each consultation and to follow the recommendations of the GP with
regard to prevention and screening. This is a moral contract, not an enforced
obligation, and there is no link with the reimbursement of care. The incentive to
enter the scheme is that patients do not have to pay in advance and then wait to
be reimbursed.
92
Primary care in the driver’s seat?
The beginning of the scheme was promising. The GP union that signed the
agreement strongly advocated the scheme, in spite of the opposition of the other
physician unions, and within a few months 12% of GPs had asked to be referring
physicians. The number of patients enrolled, though, was much lower (1%).
Then, as is often the case in France, the agreement signed by this GP union
and the health insurance funds was legally contested (by the other unions) and
cancelled in 1998. Although a new agreement, including the same scheme, was
signed in 1998 with the GPs, this time the enthusiasm of the GP union was less
clear. In its second version, the scheme was limited to about 10% of GPs and 1%
of patients. There had been complaints from GPs who joined the scheme about
the administrative workload, and the waiting time to get paid by the sickness
funds, etc. The political support of GPs as a whole for this scheme seemed
unclear, in spite of the financial incentive. Indeed, the GP union which had
signed the agreement was clearly defeated in the elections to the regional
physician organizations in 2000.
Another initiative of the 1996 reform opened up the possibility of different
forms of networks of providers, on a local basis. The aim of the experiment was
to test new forms of coordination between professionals in ambulatory care or
between ambulatory care and hospital care. The law gave a 5-year period to
experiment, also allowing these networks to experiment with financial rules
(tariffs, services reimbursed, remuneration of professionals, etc.). This innovation gave the opportunity to finance elements not taken into account by the
prior system of payment (time of coordination and management for health
professionals, information systems to share the medical records, etc.), and also
to provide new benefits for the population (joint consultations, for instance). A
large number of projects were proposed. These projects were promoted by
groups of professionals, as well as by pharmaceutical companies and even
insurers. Many were targeted at specific subpopulations (the elderly, very poor
people) or pertained to specific conditions (asthma, cancer, cardiovascular disease, diabetes) or risk factors (alcohol). Some of the networks already in place
sought to gain more financial support by applying to the scheme.
The projects were subject to the prior approval of a commission before they
could obtain specific financial rules. This commission was criticized for being
slow and discouraging promoters. However, the criteria for funding had not
been fixed by law and had to be set up by this commission. There was also a
political debate about the projects promoted by the pharmaceutical industry
and, even more so, the insurers. The most spectacular was the proposal of a
major private insurer who offered to set up a ‘managed care-like’ organization,
i.e. the insurer proposed to provide a comprehensive range of health care services (through a network of selected providers) to a population enrolled on a
voluntary basis, and to be funded by a risk-adjusted capitated payment for each
patient enrolled. This proposal was rejected by the government.
In a year and a half the commission had accepted 12 projects. At the end of
2001 the annual Act on the financing of health care changed the process in
two respects: it created a specific fund to finance the project, and transferred
the power to evaluate and accept projects to the regional level (regional
hospital agencies and regional unions of sickness funds). Since then, a series of
experiments have been initiated in all regions.
The challenge of coordination: the role of primary care professionals
93
The Croatian experience
A prominent issue in PHC in Croatia concerns the policy choice between integration versus coordination. The privatization of general practice in the 1990s
(which means GPs have individual contracts with the health insurance fund
and individually rent or buy premises for their practices) produced a shift
towards less teamwork, less group practice and overall less collaboration. As
health insurance funds do not allow joint lists of patients, i.e. group contracts, it
is impossible to organize group practices. Individual contracts in PHC are
offered to dentists, gynaecologists, paediatricians and GPs. Finally, in ‘transitional times’ the process of vocational training has not yet been well regulated
– resulting in a diminishing number of vocationally trained GPs.
Several efforts have been made to solve the problems of fragmentation and
lack of vocational training in PHC. The government as well as the health insurance funds have recognized the problem and developed initiatives to promote
group practice and stimulate vocational training. The first problem was which
type of group practice is better, monovalent (only GPs) or polivalent (GPs,
gynaecologists, etc.)? Closely related to that problem is the type of vocational
training that should be stimulated in PHC: only GPs or gynaecologists and
paediatricians together with GPs. At this time, vocational training in general
practice with the GP as the only contractor in PHC is the most likely option.
Regarding coordination with secondary health care, these initiatives are
designed to make task allocations clearer, but tend to create problems in
communication/collaboration with secondary care. While there are recent
initiatives, most GPs currently work in “given circumstances”: single contract,
strict list, more or less single practice.
Two new models of coordination can be identified among GPs. Both are
products of GPs’ awareness that something better could be arranged. One spontaneously created project is the network of ‘open-gate practices’. A group of GPs
from all over the country have opened the doors of their practices to patients
from other general practices. Temporary registration is not a possibility in
Croatia and if they fall ill while staying in another city patients can use only
emergency departments. If assigned to one of the GPs within the network,
patients could use services and get prescriptions from any other GP in the
network.
A second new model of coordination in PHC, in Croatia, is the (PHC) polyclinic run by GPs. GPs who run these policlinics are working as contractual
doctors for a health insurance fund and specialists in polyclinics are working
without contract for direct patient payment. It reflects GPs’ need to own or rent
premises for starting a practice and obtaining a contract with the health insurance fund. However, financing through this contractual arrangement is not
sufficient to cover the costs of buying premises. For that reason GPs buy more
space and rent it to consultants/specialists. This enables the GPs to cover the
costs of investment and also to offer more services to patients. This usually leads
to more patients choosing the GP’s practice, more patients on his or her list and
more money through the contract. The GP can also arrange a different sort of
contract to consulting doctors working in his or her clinic. Consultants can be
paid a salary and payment for consultation can be collected by the polyclinic
94
Primary care in the driver’s seat?
owner, i.e. the GP. Also, part of the fee for the service payment of consultants
can be collected by the policlinic owner. As services of consultants are paid
by patients and not by health insurance there are no limitations on services.
GPs can be more secure because expert consultation is available on site and
misconduct/malpractice can be prevented. Also, mutual informal education
and consultation can be achieved, although no formal education and CME
points could be gained though such work.
From the patients’ point of view, this model has both positive and negative
aspects.
On the positive side, it offers more convenient specialist consultation for
patients in remote areas. Mutual consultation and education between doctors
reduce clinical errors and an expert team can be formed on site to deal with
more complicated conditions. However, on the negative side, most of the
services are not covered by health insurance and there is a possibility of
unnecessary provider-generated services.
The Dutch experience
In the Netherlands, a distinction can be made between two kinds of strategies.
The first is strengthening the gatekeeping position of GPs. The second is the
development of new organizational models of integrated care, which is called
“transmural care”.
Strengthening general practice
In the Netherlands, general practice has been dominated by individual practices. Only recently the percentage of GPs working in partnerships or in health
centres has exceeded the percentage of GPs working in individual practice. This
implies that individual GPs have a weaker position compared to larger health
care organizations such as hospitals, home care organizations and nursing
homes. A study by Kersten (1991) showed, for instance, that, despite their position as gatekeepers, the influence of GPs is rather limited on the care their
patients receive in a hospital. Therefore, since the beginning of the 1990s,
organizational changes in general practice have been introduced. All general
practices are now part of so-called GP-groups (HAGROs). Often these HAGROs
(or one of their members) negotiate with hospitals and participate in development projects in the field of coordination. Furthermore, GPs participate in
so-called FTOs: groups of GPs and pharmacists that discuss and coordinate the
prescription of drugs. Also, the introduction of practice nurses, who are especially employed to coordinate care for special groups of patients (diabetes,
rheumatism) can be seen as a measure to strengthen the central coordinating
function of general practice.
Recently the organization of emergency and out-of-office hours care has been
changing, especially in larger urban areas. Traditionally this was arranged in
small GP groups in which the participating GPs took over the responsibility of
each other’s patients (the locum system). Now, local large-scale GP services are
established in which a limited number of GPs are on duty (during out-of-office
The challenge of coordination: the role of primary care professionals
95
hours) for the total population living in a particular town or area. They are
supported by a car with a driver, a call centre (often staffed by specially trained
nurses) which makes the first selection in patients’ calls, and a central building
which can be visited by patients.
Transmural care
Since the mid-1990s, serious attempts have been made to create new organizational forms of “integrated care” in the Netherlands. Two committees (Committee for the Modernization of Curative Care and an advisory committee of the
National Council for Public Health) formulated new proposals to improve quality and efficiency in the Dutch health care system (Commissie Modernisering
Curatieve Zorg, 1994; NRV/CvZ, 1995). In contrast to the implementation of
other reforms, no comprehensive programme of reform of change was
developed. Instead a bottom-up approach was chosen. The idea was that
cooperation and communication between primary and secondary care providers could only be realized at a local or regional level. The process depends to a
large extent on direct interpersonal relationships. A number of general changes
in the organization and financing of primary care and secondary care were
proposed, which could indirectly benefit initiatives for integrated care.
The main problem to solve through integrated care is the (organizational) gap
between primary and secondary health care. This can be achieved by the creation of new forms of care – “transmural care” – which breaks down the traditional boundaries between primary and secondary care. The most frequently
used definition of transmural care is: care, attuned to the needs of the patient,
provided on the basis of close collaboration (cooperation and coordination)
between primary and specialized care providers, with joint overall responsibility
and the specification of delegated responsibilities (NRV/CvZ, 1995). Close collaboration implies collaboration between health professionals on a formal
structural basis (Temmink, 2000). This can be organized in regular meetings
between care providers, in which patient-related subjects as well as the preconditions of the transmural care process are discussed. Joint responsibility
refers to formal agreements about the transmural care process at an organizational level. Such agreements can be laid down in protocols or guidelines.
There are now many forms of transmural care. Van der Linden (2001) made an
inventory of types of transmural care that were established in 1999. She found a
total of more than 500 projects which were categorized in seven groups:
1. Specialized nurse clinics for chronic patient sufferers of asthma, diabetes, and
rheumatic diseases.
2. Guideline development at national level as well as at regional level for specific diagnoses such as asthma and low fertility. In some areas local guidelines are developed about the patient flows in the organization of care (e.g.
discharge protocols, patient information/education guidelines and clinical
agreements about the treatment).
3. Home care technology to provide specialist care at home (hospital at home).
4. Discharge planning by the introduction of specialized liaison or transfer
nurses.
96
Primary care in the driver’s seat?
5. Consultation of medical specialists and use of hospital facilities by GPs (e.g.
feedback on the interpretation of the results of diagnostic tests, prescription
of drugs and referrals).
6. Rehabilitation wards for patients who require temporary post-acute care after
hospitalization (e.g. stabilized stroke patients or post-operative hip patients).
7. Initiatives for streamlining prescription and delivery of drugs.
The organizational structures of these initiatives differ. Some specific forms of
transmural care are organized in special groups such as palliative networks and
are called “pain teams”, which mostly operate in the community. In these kind
of organizational units GPs often play a central, coordinating role. First results
of some evaluative studies indicate that new organizational forms that increase
continuity of care are more cost-effective and lead to higher patient satisfaction,
as the needs of individual patients can better be met than in the traditional
situation (see, for example, Smelt et al., 1999; Francke and Willems, 2000).
Other forms of transmural care are situated in the hospital. An experiment in
this respect is the start of a so-called GP ward in a general hospital. At this ward,
patients are treated under the responsibility of the GP. The groups of patients
mainly consist of patients who are not fully recovered from day surgery or an
operation in a hospital far from the patient’s place of residence, “bedblockers”(non-medical specialist treatment needed or possible and waiting for a
place in a nursing home) and other patients who can no longer be treated at
home with a low care profile. The participating GPs were positive about the
results of this new organizational form (Moll van Charante et al., 2001).
Another successful transmural innovation is the establishment of stroke units
in which GPs, home care organizations, hospitals and nursing homes participate. The increase of cooperation and coordination in these units results in
better quality of care, better health outcomes, less “bed-blockers” and more
cost-effective care compared to the traditional provision of care (Huisman
et al., 2001). The stroke unit is best situated in a comprehensive organization
including in- and outpatient care (Kwa, 2002).
The “bottom-up” approach has led to regional variations in the provision of
health care services. Some regions have only few “transmural” initiatives, while
in some other regions so called “chains of care” (zorgketens) are formatted. These
are regional cooperations of different care-providing organizations, which work
together on a formalized or institutionalized basis. The impact of the new
transmural initiatives on the gatekeeping position of Dutch GPs is not clear yet.
The inventory by Van der Linden (2001) showed that home care organizations,
hospitals and nursing homes have a more prominent role in transmural care
projects than GPs. Besides, it is unknown how transmural care will develop in
the near future. There are still problems regarding the implementation of the
(experimental) projects into the daily routine of care provision. The main problems include the financial system, which is not tailored to integrated care, the
lack of ICT supports and a shortage of care providers in primary as well as
secondary care.
The challenge of coordination: the role of primary care professionals
97
The United Kingdom experience
Over the last decade United Kingdom government policy has placed an increasing emphasis on the notion of a primary-care-led NHS, with an attempt to shift
power and resources from secondary to primary care so as to bring planning and
provision of care “closer to patients” (Somerset et al., 1999). Initiatives such
as fundholding, the total purchasing pilots, Primary Care Groups (PCGs) now
Primary Care Trusts (PCTs), and the pilot salaried schemes are all attempts to tip
the balance of care further in the direction of the primary and community
sector, and away from the hospital sector (Coulter and Mays, 1997). These initiatives have implications for the coordinating role of general practice. Two that
are of most significance are fundholding and the introduction of PCGs and
PCTs. Fundholding was introduced in the NHS in the early 1990s as a result of
the creation of the internal market by the Conservative Government. The
introduction of PCGs and PCTs was an initiative taken in the latter part of the
1990s by the Labour Government (Dixon et al., 1998).
The fundholding initiative (Glennerster et al., 1994) allowed general practices
to become fundholders and these practices could place contracts for nonemergency care for their patients. With individual patients having no purchasing rights of their own, GP fund holders were to act as proxies, purchasing
services on patients’ behalf. This initiative, along with other developments in
the 1970s and 1980s that enhanced the professional status of GPs (see Calnan
and Gabe, 1991), to some extent countered the problems of coordination due to
the unequal relationship between GPs and hospital doctors. It attempted to give
more power (through control over resources) to GPs in their negotiations with
hospital doctors. There is some evidence that fundholding GPs, as proxy consumers, acted in their patients’ best interests and strengthened their coordinating role. For example, there is evidence that communication between GPs and
hospital doctors improved and fundholding facilitated improvements in services, such as quicker diagnostic test results and shorter waiting times. They
were also able to buy in specialist services such as physiotherapy and outreach
clinics. However, fundholding was not cost-effective owing to the increased
bureaucracy and did create inequalities in access (Coulter, 1995) and there was
little evidence that the contracting process actually strengthened the negotiating power of GPs (Baeza and Calnan, 1997). The stimulus for hospital doctors to
adhere to fundholders’ demands depended on the existence of other alternative
sources of supply and provision. In many cases fundholders were loyal and
supportive to their local providers rather than shopping around for hospital care
(Robinson and Le Grand, 1994; Mays et al., 2001).
One initiative which emerged from the implementation of fundholding was
the introduction of outreach clinics in general practice (Abery et al., 1998),
which is an example of promoting integration by providing services in primary
care that are normally based in hospital. One study (Gillam et al., 1995) evaluated an outreach model of ophthalmic care in terms of its impact on general
practitioners, their use of ophthalmology services, patient views and costs. An
ophthalmic medical practitioner and an ophthalmic nurse held clinics in the 17
participating practices once a month. The clinic was popular with patients and
general practitioners and appeared to act as an effective filter for demand for
98 Primary care in the driver’s seat?
care in the hospital setting. However, the educational impact of the scheme was
limited and the cost per patient serving the outreach clinic was about three
times the cost per patient seen in the outpatient clinic.
There have been a number of other initiatives (see Sergison et al., 1997) aimed
at improving coordination between primary care and specialist hospital services. One approach has been to allocate a specific coordinating role to a nurse
or doctor (O’Leary, 1990; Grahame and West, 1996). Another is setting up an
organizational arrangement for shared care for patients with chronic conditions
such as diabetes or asthma or for specific services such as antenatal and obstetric
care (Tucker et al., 1996). A related model involves follow-up after hospital discharge (Hansen et al., 1992). However, the overall impact of these different
initiatives appears to be limited as there is some evidence (Evans, 1996) to suggest that, while primary care-led initiatives in the NHS may have improved
communication and increased direct access to facilities, there is little evidence
of a shift in resources and services to primary care. Important barriers to change
included the attitudes of consultants and the individualistic culture of GPs.
The fundholding system has been replaced by PCGs, which have now become
PCTs. The establishment of PCGs and PCTs reflected the clear policy aim of
developing integrated care by bringing together primary care with community
services and by linking the provision of care with a major responsibility for
commissioning (Ham, 2004). A national network of PCGs was established in
England in 1999 and PCGs had three core functions: to improve the health of
the population in the PCG, to develop primary and community health services
within the PCG and to commission secondary and tertiary services for the population in the PCG. However, PCGs were considered to be the first stage of a
process resulting in the eventual transition to PCTs (Mays and Goodwin, 1998).
PCTs were to be free standing and comprise GPs and community nurses, commissioning services for their populations, and managing the provision of community services such as district nursing and health visiting, while remaining
accountable to the local health authority. PCTs had the same functions as PCGs,
but with a greater range of responsibilities. Accordingly, PCTs received a unified
budget, which represents approximately 80% of the health care budget.
In April 2002 around 300 primary care trusts were formed with strategic
health authorities leading the strategic development of the local health community and managing the performance of PCTs and NHS trusts. This left PCTs
with the lead NHS role of improving the health of the community, developing
primary and community health services, and commissioning secondary care
services. Each PCT is run by a board comprising a lay chairman, non-executive
director and a minority of executive directors, including the chief executive, the
finance director and the director of public health (Ham, 2004). The limited
evidence available about the impact of PCGs and PCTs suggests developments
in the commissioning of primary and community services, reflecting a desire to
initiate alternatives to services traditionally delivered in the secondary sector.
Significant progress had particularly been made in commissioning in the areas
of community services, primary care and intermediate care (Smith and Goodwin,
2002). However, in the commissioning of acute services, developments have
been slower and less significant. This was due in part to the lack of involvement
from primary and secondary care doctors and continued poor relations and
The challenge of coordination: the role of primary care professionals
99
communication between the primary and secondary sectors (Regen et al., 2001).
Evidence from this study (Regen, 2002) also showed that the majority of GPs felt
that the added workload associated with PCGs and PCTs had not translated into
tangible service improvements in terms of the quality and range of practice
services, and that gaining GPs effective involvement in PCTs was proving
problematic.
A more recent development (Department of Health, 2004) has been the introduction of practice-based commissioning. From April 2005, practices can
receive an “indicative budget” from Primary Care Trusts which they can use to
improve the delivery of services. The case study sites where such schemes have
been tested suggest patients will have access to alternative pathways of care
across primary and secondary care with an emphasis on providing specialist
care in general practice. Such an initiative appears to mirror fundholding
developed in the early 1990s, although this was within the different context of
the quasi-market.
Discussion
This analysis shows clearly that fragmented care and problems of coordination
and continuity of care tend to be prevalent irrespective of the type of health care
system. In the Netherlands and the United Kingdom, there are still problems of
coordination and integration despite the presence of GP gatekeeping and
coordinating systems. However, these problems of fragmentation tend to be
exacerbated in systems where there is no GP gatekeeping system and the
emphasis is placed on “choice”, with patients bearing the major responsibility
for navigating their own pathway through the health service.
The analysis has also shown the various strategies adopted by four different
countries for addressing the problems of fragmentation. One strategy common
to all countries was to strengthen general practice, although the driving force
behind this policy was as much for reasons of economic efficiency as a concern
for patient needs. The introduction of Primary Care Trusts in the United Kingdom, for example, has sought to achieve closer integration between primary
care and community health services. An alternative strategy adopted by many
countries was to attempt to enhance coordination between primary care
and the specialist services, social care and community services. It appears that
GPs control the access to the gate but their coordination powers recede after
the patient passes the gate. These initiatives included allocating a specific
coordination role to a health or social care professional, setting up organizational arrangements for shared care or joint commissioning and introducing
services which were usually based in the hospital or social service and transferring them to general practice. The evidence available to assess the benefits of
these initiatives is variable, with their success tending to hinge on the willingness of different branches of the medical profession to work together (Evans,
1996).
These organizational changes were typically introduced to strengthen the
gatekeeping role, although recent, associated policy initiatives appear to be
challenging the basic concept of gatekeeping and particularly continuity of care
100 Primary care in the driver’s seat?
(Bosanquet and Salisbury, 1998). For example, in the “new” modernized NHS in
the United Kingdom a number of developments have taken place that might be
seen as challenges. First, there has been an increase in the points of entry for
patients in primary care. Examples of these are NHS Walk-in Centres (Anderson
et al., 2002; Salisbury, 2004), NHS Direct (call-in centre) and GPs working in
larger organizations, such as cooperatives for out-of-hours care, which are dealing with increasing proportions of the primary care workload. Each of these
enables the patient to have direct access to health care and have access to a
different health professional.
The second challenge is to the concept of continuity of care. Increasingly,
patients do not know the doctors that treat them on a personal basis. This is
partly owing to the increase in patients moving or changing doctors, but mainly
to the fact that fewer doctors want to work full-time and that practices are
generally larger in size. A salaried system has been piloted which, while
encouraging GPs to work in deprived areas, is seen by many GPs as a temporary
position with little opportunity for patients and doctors to develop a close
relationship.
A third challenge in the United Kingdom is the emergence of a specialist role
for GPs. GP specialist services such as dermatology have been organized and run
by specialist GPs and nurses, providing a substitute for the hospital service. This
initiative is targeted mainly at controlling waiting lists. This stands in contrast
to the outreach clinics, which emerged from the internal market initiative,
where hospital specialists provided clinics based in general practice. In addition,
there is a new attempt to involve GPs in local hospitals or community hospitals
and what are currently termed “intermediate care systems”.
Finally, a fourth challenge is the introduction of the primary health care team
and the introduction of nurses (triage) as the first point of contact. In this context GPs are primary care consultants and nurses would deal with a range of
activities such as acute care monitoring, health promotion and chronic disease
management.
Some of these developments are evident in the new GP contract (Department
of Health, 2003; Rowland, 2004), which distinguishes between core activities of
GPs “serving people who are ill”, additional activities (optional, such as maternity care) and other activities (specialist services), which are provided at PCT
level. Thus, increasingly patients would be consulting different professionals for
primary care services. This may meet patient demands, or some groups of
patient demands, but it challenges the notion of continuity of care. Thus, the
new drive for a primary care led NHS may have increased access to primary care
and specialist care but it appears to challenge the notion of continuity of care
and the coordinating role of the GP. It might be that patients will have to give
up the benefits of a “personal” doctor for the advantages of a primary care-based
service where the coordinating role is provided through the organization itself.
This might be suitable for some types of patients, but for those who value a
doctor “who knows you”, such as those with chronic illness and multiple
illnesses, this development might be seen as an additional barrier to access
(Calnan et al., 1994).
These developments, problems and solutions are also evident in other countries where primary care has a central role, e.g. the Netherlands. However,
The challenge of coordination: the role of primary care professionals
101
possible general policies for improving coordination, irrespective of the health
care system, might include:
• defining the (patient) population beforehand (agreements about diagnostic
tests, interpretations, definitions, etc.);
• defining a common package of care activities around the specific needs of a
patient group;
• defining shared responsibility and separate responsibilities of the care providing partners;
• creating mutual respect and trust (e.g. by the development of protocols or
•
•
•
appointments about the care process);
establishing clear financial arrangements beforehand (e.g. for the extra time
and administrative work related to cooperation and communication);
improving communication and information facilities (ICT); and
introducing elements of integrated care in educational programmes (e.g. into
continuous medical education).
Notes
1
2
There is a carnet de santé for children, and this is totally accepted, because it helps
parents to keep track of all health events of the child and is very useful for both the
family and the physicians. But it has no link whatsoever with a cost-containment
objective.
The other physician organizations were strongly opposed to this reform, which tried
to establish a financial ceiling for physicians’ expenditure.
References
Abery, A., Bond, M., Bowling, A., McClay, M. and Pope, G. (1998). Evaluation of specialists’ outreach clinics in primary care in England, Quality of Life Newsletter 16: 7–8.
Anderson, E., Pope, C., Manka-Scott, T. and Salisbury, C. (2002). NHS walk-in centres and
the expanding role of primary care nurses, Nursing Times 98(19): 36–37.
Baeza, J. and Calnan, M. (1997). Implementing quality: a study of the adoption and
implementation of quality standards in the contracting process in a general
practitioner multifund, Journal of Health Services and Research Policy 2(4): 205–11.
Bosanquet, N. and Salisbury, C. (1998). The practice, in Loudon, I., Horder, J. and Webster, C. (eds) General Practice under the National Health Service 1948–1997, London:
Clarendon Press.
Calnan, M. and Gabe, J. (1991). Sociology of General Practice, in: Gabe, J., Calnan, M. and
Bury, M. (eds) Sociology of the Health Service. London/New York: Routledge.
Calnan, M., Coyle, J. and Williams, S. (1994). Changing perceptions of general
practitioner care, European Journal of Public Health 4: 108–114.
Commissie Modernisering Curatieve Zorg (1994). Rapport Gedeelde Zorg: betere zorg.
Zoetermeer: Hageman BV.
Coulter, A. (1995). Evaluating general practice fundholding in the UK, European Journal of
Public Health 5(4): 233–239.
Coulter, A. and Mays, N. (1997). Deregulating Primary Care, British Medical Journal 314:
510–513.
102 Primary care in the driver’s seat?
Delnoij, D.M.J., Van Merode, G., Paulus, A. and Groenewegen, P.P. (2000). Does general
practitioner curb health care expenditure?, Journal of Health Services Research and Policy
1: 22–26.
Department of Health (2003). Investing in General Practice: The New General Medical Services
Contract: The Stationery Office. London: Department of Health.
Department of Health (2004). Practice Based Commissioning: Engaging Practices in Commissioning. London: Department of Health. (http://www.dh.gov.uk/assetRoot/04/09/03/
59/04090359.pdf, accessed 28 October).
De Roo, A.A., Chambaud, L. and Güntert, B.J. (2004). Long-term care in social health
insurance systems, in Saltman, R.B., Busse, R. and Figueras, J. (eds) Social Health
Insurance Systems in Western Europe. Berkshire/New York: Open University Press/
McGraw-Hill Education.
Dixon, J., Holland, P. and Mays, N. (1998). Developing primary care gatekeeping, commissioning and managed care, British Medical Journal 317: 125–8.
Evans, D. (1996). A stakeholder analysis of developments at the primary and secondary care
interface. Institute for Health Policy Studies, University of Southampton.
Francke, A.L. and Willems, D.L. (2000). Palliatieve zorg vandaag en morgen. Feiten, opvattingen en scenario’s [Palliative care today and tomorrow. Facts, opinions and scenarios].
Maarssen: Elsevier gezondheidszorg.
Gervas, J., Perez-Fernandez, M. and Starfield, B.H. (1994). Primary care, financing and
gatekeeping in western Europe, Family Practice 11(3): 307–17.
Gillam, S.T., Ball, M., Pruesad, M., Dunne, H., Cohen, S. and Vaflides, G. (1995). Investigation of benefits and costs of an ophthalmic outreach clinic in general practice, British
Journal of General Practice 45: 649–652.
Glendinning, C., Rummery, K. and Clarke, R. (1998). From collaboartion to commissioning: developing relationships between primary health and social services, British
Medical Journal 317(7151): 122–5.
Glennerster, H., Matsaganis, W. and Owens, P. (1994). Implementing GP Fund Holding: Wild
Card or Winning Hand? Buckingham: Open University Press.
Grahame, R. and West, J. (1996). The role of the rheumatology nurse practitioner in
primary care: an experiment in the further education of the practice nurse, British
Journal of Rheumatology 35(6): 581–8.
Gross, R., Tabenkin, H. and Brammli-Greenberg, S. (2000). Who needs a gatekeeper? Patients’ views of the role of the primary care physician, Family Practice 17:
222–229.
Grundmeyer, H.G.L.M. (1996). General practitioner and specialist: why do they communicate so badly? European Journal of General Practice 2: 53–54.
Halm, E.A., Causino, N. and Blumenthal, D. (1997). Is gatekeeping better than traditional
care? A survey of physicians’ attitudes, Journal of the American Medical Association 26:
1677–1681.
Ham, C. (2004). Health Policy in Britain: The Politics and Organisation of the National Health
Service (5th edition). Hampshire: Palgrave Macmillan.
Hansen, F.R., Spedtsberg, K. and Schroll, M. (1992). General follow up by home visits after
discharge from hospital, Age and Ageing 21(6): 445–450.
Huisman, R., Van Wijngaarden, J.D.H., Scholte op Reimer, W.J.M. et al. (2001). Van units
naar ketenzorg: stroke service biedt betere zorg voor CVA-patiënten [From units to
chain-care: stroke service provides better care for stroke patients], Medisch Contact
56(48): 1765–1768.
Hutten, J.B.F. (1998). Workload and provision of care in general practice. An empirical
study of the relation between the workload of Dutch general practitioners and the
content and quality of their care. Utrecht: NIVEL (thesis, University of Utrecht).
Kersten, T.J.J.M.T. (1991). De invloed van huisartsen in de tweede lijn [The influence of
The challenge of coordination: the role of primary care professionals
103
general practitioners on secondary care]. Utrecht: NIVEL (thesis, University of
Utrecht).
Kwa, V.I.H. (2002). “Stroke units” als effectiefste vorm van behandeling [“Stroke units” as
most effective form of care], Pharmaceutisch weekblad 137(9): 319–322.
Mays, N. and Goodwin, N. (1998). Primary care groups in England, in Klein, R. (ed.)
Implementing the White Paper – Pitfalls and Opportunities. London: King’s Fund.
Mays, N., Wyke, S., Malbon, G. and Goodwin, N. (eds) (2001). The Purchasing of Health
Care by Primary Care Organisations. Buckinghamshire: Open University Press.
Moll van Charante, E.P., Ijzermans, C.J., Hartman, E.E. et al. (2001). De huisartskliniek in
Ijmuiden: een inventarisend onderzoek [The general practitioner clinic in Ijmuiden: an inventory-making investigation]. Amsterdam/Rotterdam: Instituut voor Huisartsgeneeskunde Amsterdam, Institute of Medical Technology Assessment.
Moll van Charante, E.P., Delnoij, D.M.J., Ijzermans, C.J. and Klazinga, N.S. (2002). Van
spelverdeler tot speelbal? De veranderde rol en positie van de Nederlandse huisarts
[The changing role of the Dutch general practitioner], Huisarts en Wetenschap 45(2):
70–75.
NRV/CvZ (1995). Transmurale somatische zorg. Zoetermeer: NRV/CvZ.
O’Leary, J. (1990). Primary health care. Liaison nursing. Forging vital links in care. Nursing
Standard 5(7): 52.
Preston, C., Cheater, F., Baker, R. and Hearnshaw, H. (1999). Left in limbo: patients’
views on care across the primary/secondary interface, Quality in Health Care 8(1):
16–21.
Regen, E. (2002). Driving Seat or Back Seat? GPs’ Views on and Involvement in Primary Care
Groups and Trusts. Birmingham: Health Services Management Centre.
Regen, M., Smith, J., Goodwin, N., Mcleod, H. and Shapiro, J. (2001). Passing on the Baton:
Final Report of a National Evaluation of Primary Care Groups and Trusts. Birmingham:
Health Services Management Centre.
Roberts, K.J. (1999). Patient empowerment in the United States: a critical commentary,
Health Expectations 2: 82–92.
Robinson, R. and Le Grand, J. (1994). Evaluating the NHS Reforms. London: King’s Fund.
Rowland, M. (2004). Linking physicians pay to the quality of care – a major experiment in
the UK, New England Journal of Medicine 351(14): 1448–1453.
Salisbury, C. (2004). Does advanced access work for patients and practices? British Journal
of General Practice 54: 330–31.
Sergison, M., Sibbald, B. and Rose, S. (1997). Skill Mix in PC: A Bibliography. NCRPC,
working paper. Manchester: University of Manchester.
Shi, L., Starfield, B., Kennedy, B. and Kawachi, I. (1999). Income inequality, primary care
and health indicators, Journal of Family Practice 48(4): 275–84.
Smelt, W.L.H., De Gier, A., Meyer, C., De Bruijn, M., Oudendijk, C. and Van der Kam, W.L.
(1999). Huisarts spil in pijnteam: chronische patiënten eerder geholpen [General
practitioner at the centre of painteam: prompt care for chronic patients], Medisch
Contact 54(48): 1663–1665.
Smith, J. and Goodwin, N. (2002). Developing Effective Commissioning by Primary Care
Trusts: Lessons from the Research Evidence. Birmingham: Health Services Management
Centre.
Somerset, M., Faulkner, A., Shaw, A., Dunn, L. and Sharp, D.J. (1999). Obstacles on the
path to a primary care led NHS: complexities of outpatient, Social Science and Medicine
48(2): 213–225.
Starfield, B. (1991). Primary care and health, Journal of the American Medical Association
266(16): 2268–2271.
Temmink, D. (2000) Transmural Clinics: A Nursing Innovation Explored. Thesis: Maastricht
University. Utrecht: NIVEL.
104 Primary care in the driver’s seat?
Tucker, J.S., Hall, M.N., Howie, P.W. et al. (1996). Should obstreticians see women with
normal pregnancies? British Medical Journal 312: 554–559.
Van der Linden, B.A. (2001). The Birth of Integration: explorative studies on the development
and implementation of transmural care in the Netherlands 1994–2000. Utrecht:
University of Utrecht (thesis).
Wilsford, D. (1991). Doctors and the State: The Politics of Health Care in France and the United
States. Durham: Duke University Press.
chapter
six
The impact of primary
care purchasing in Europe:
a comparative case study
of primary care reform1
Alison McCallum, Mats Brommels,
Ray Robinson, Sven-Eric Bergman
and Toomas Palu
Introduction and background
Development of purchasing in health care
In recent years several countries have sought to develop organizations that
purchase services to reflect strategic health care objectives. These organizations
decide which health services to purchase for a population, the terms on which
they should be purchased and which organizations should provide them.
Potential purchasers include sickness funds in countries with social health
insurance systems and local health agencies or municipalities in tax-based
health systems. Primary care purchasing occurs where responsibility for a
budget, for specialist services or for additional primary care is devolved to
primary care practitioners or organizations.
Theoretical benefits of purchasing
The stated advantage of a distinct purchasing function is its focus on population
health needs. Purchasing provides opportunities to change historic patterns of
service use and reallocate resources to prevent provider capture of the health
care agenda. Various incentives associated with devolved decision-making can
106 Primary care in the driver’s seat?
also improve the flexibility and performance of the health system. Purchasing
might enable changes in which the hospital or organization provides services,
the balance between in patient and ambulatory care, or the development of
clinical rather than administrative quality standards.
Where primary care practitioners or organizations purchase care, several
benefits are considered more likely to occur than when sickness funds or local
health agencies adopt this role. Primary care purchasing should combine financial and clinical decision-making and provide incentives for GPs to use limited
resources more cost-effectively. It should streamline services, making them
more patient-focused and influencing the balance of power between primary
care and specialist services.
The theoretical benefits of primary care purchasing reflect its flexibility,
personal and local scale and lack of bureaucracy. Centralized institutions,
particularly those like sickness funds, where efficient claims processing and
reimbursement require well-developed bureaucracy, might find it difficult to
adopt the necessary flexibility and local responsiveness. Disadvantages for
hospitals as purchasers include their larger scale and tendency to reduce
the influence and resources available to primary care. Potential exceptions
include hospitals with a strong community focus, an emphasis on chronic
disease management and access to expert primary care.
The continuum of primary care purchasing in Europe
Over the last 20 years various models of primary health care purchasing have
developed. They range from market-based solutions to networks of communityfocused organizations. The different models reflect the power of various stakeholders, their reasons for considering primary care purchasing and the prevailing
ideology. The most comprehensive examples occur where primary care organizes and finances all aspects of prevention, treatment and care, from community
development, drug treatment, diagnostic services and commissioning to specialist medical, surgical and psychiatric care. This is the situation in Britain,
where Primary Care Trusts purchase community and specialist services for all
but the most complex treatments with a fixed budget.
At the other end of the spectrum GPs influence purchasing indirectly through
professional representation on various committees. This tends to occur in
health care systems based on social insurance. Between these extremes, budgets
for specific services and programmes are devolved. Together these form a
continuum of different models of purchasing or devolved budgeting. Table 6.1
illustrates the four main categories.
The range of contracting tools employed in primary
care purchasing
The other dimension of purchasing is the sphere of influence within which
primary care purchasers operate. This ranges from the ability to shape everyday
The impact of primary care purchasing in Europe
107
Table 6.1 Models of primary care purchasing and devolved budgeting
Model
Main features
Active purchasing
Funds transferred to the primary care budget
Degree of organizational autonomy
May include financial incentives or risks to encourage
different ways of working
Commissioning
Primary care determines nature and content of specific
specialist services
Indicative budget transferred
Formal financial accountability (for example, contract
signing) remains with a parent organization
Budget transfer
Responsibility for funding specific services, for example
diagnostic tests or pharmaceuticals transferred
Limited influence over service delivery
Indirect purchasing
Exercise of representative power or professional influence
over purchasing by a third party, e.g. member of group
advising social insurance institutions
practice, to plan enhanced primary and community care provision, through to
primary care leadership of specialist care redesign.
The purchasing model and sphere of influence affect the nature of contracts
as well as similar agreements by primary care purchasers and bodies responsible
for overseeing processes. Examples include the availability of information,
analysis and expertise to identify and prioritize the care included in contracts,
the nature of the contractual relationships, and the mechanisms for enforcing
and ending contracts, including the ability to change providers. Effective professional, managerial and financial controls are required to detect unforeseen
adverse effects of contracts, to limit financial risks that might disrupt patient
care and to reduce gaming.
Evaluating the impact of primary care purchasing
This chapter examines the development and impact of these models of primary
care purchasing and commissioning on the organization and development of
health services. Sources include published literature and expert opinion.
These were appraised using comparative case study methods and cross-case
analysis to compare findings across countries and identify lessons that could
be generalized.
Evaluation of the success of purchasing experiments in primary care has three
elements. First, was the implementation of primary care purchasing successful?
Second, did the purchasing experiment achieve the improvements in health
service organization, care processes and outcomes that were anticipated? Third,
what factors facilitated or constrained the implementation and impact of
108 Primary care in the driver’s seat?
primary care purchasing? The cases illustrate the continuum from active to
indirect purchasing and the range and scope of the initiatives that have
developed in each category.
The development of primary care purchasing in England2
GP fundholding
Since the 1980s, various reforms have laid the groundwork for primary care
purchasing. Preliminary reforms in 1985 and 1990 increased local GP, and thus
primary care, accountability before purchasing was devolved (Taylor, 1991;
Allsop, 1995; Bloor et al., 1999). In 1991 general practice fundholding was established, and 303 GP practices with patient list sizes of 11,000 or more received
budgets to purchase selected services directly for their patients (Glennerster
et al., 1994). The standard fundholding budget covered about 20% of the hospital and community health service budget, including most elective surgery
(cataract extraction, hip replacements, etc.), ambulatory (outpatient) assessment, diagnosis, treatment and prescription costs. The local health authority
purchased all other services, including emergency care. The fundholding budget
excluded the GPs’ personal income, which was paid separately. Practices could
reallocate fundholding savings to other services but not to supplement GPs’
income. Although cash limits were applied to health authorities and NHS
trusts, and thus non-fundholder purchasing, fundholder overspending was
tolerated.
Fundholding evolved (Mays and Dixon, 1996) to incorporate more complex
procedures and services, for example cardiovascular surgery and specialized
nursing care. Fundholding was also adapted for smaller practices; from April
1996, practices with lists of 5000 or more patients were eligible to apply. Practices with 3000 to 5000 patients could purchase community services included
in the standard fundholding budget. This “community” model allowed small,
even single-handed, GP practices to become fundholders.
At the other end of the scale, more sophisticated organizations developed.
These included practice consortia and multifunds. Here fundholding practices
pooled some management functions, achieving economies of scale without
jeopardizing the flexibility of fundholding. This combination of initiatives
extended fundholding across the range of primary care. The proportion of
the population covered by fundholding increased from 7% in 1991 to over 50%
in 1997.
Total purchasing pilots
In 1996 selected Total Purchasing Pilots (TPPs) were introduced to purchase
all but highly specialist services (Total Purchasing National Evaluation Team
1997). The average first-wave TPP comprised four general practices and
20 GPs and an average patient population of 31,300 (ranged 8100 to 84,700).
The second wave included one health authority area covering over 300,000
The impact of primary care purchasing in Europe
109
people. This experiment, unlike fundholding, was independently evaluated for
evidence of improved management practice, cost-effectiveness and patient
benefits.
GP commissioning
Despite its growth, GP fundholding remained controversial (Robinson and
Hayter, 1995). Non-fundholding organizations, called GP commissioning
groups, developed as parallel purchasers. They aimed to change primary care
and specialist services through collaboration rather than contracting. Although
budgets and responsibility for commissioning were devolved to the commissioning groups, technically, contracts were held between the health authority
and the provider.
Primary Care Groups and Trusts
Primary Care Groups replaced fundholding and commissioning groups between
1999 and 2002. These organizations were to maintain service improvements
introduced by some fundholders and GP commissioning groups but with lower
transaction costs and without the fragmentation, duplication and perceived
inequities in service development created by fundholding (Department of
Health, 1997).
Initially, 481 PCGs were established around local communities. The average
population served was 100,000 people, but ranged from 50,000 to over 250,000.
Unlike fundholding, PCG membership was compulsory. PCGs were health
authority subcommittees with a multiagency governing body, although GPs
formed the majority. PCG commissioning occurred within the framework of the
local health authority’s Health Improvement Programme and in collaboration
with other local organizations. Three-year service agreements replaced contracts
but monthly monitoring continued.
The four levels of PCG differed in the range and scope of their purchasing. At
Level 1, PCGs were commissioning advisors to health authorities. Budgetary
responsibility and independence increased up to level 4. Here, PCGs commissioned care for the PCG population and provided community health services.
PCGs at levels 3 and 4 became Primary Care Trusts.
In April 2002, Primary Care Trusts were established as independent organizations across England and district health authorities were abolished. PCT chief
executives are responsible for ensuring local clinical quality and financial control within a nationally agreed framework. PCTs make primary care the centre of
decision-making and local health strategy. They commission all but highly specialist services for populations of around 80,000 to 300,000 and are responsible
for 75–80% of the NHS budget. PCTs combine purchasers and provider functions; their structure and requirement to adopt systematic approaches to collaboration are intended to facilitate commissioning of care that is integrated
across the health, social care and independent sectors.
110 Primary care in the driver’s seat?
Purchasing service redesign
The level of optimism about PCT sustainability varies; calls for a return to local,
less bureaucratic organizations than PCTs and recommendations for mergers
have both been reported (Honey et al., 2003; Gould, 2004). The establishment of
NHS Foundation Trusts promised increased freedom from local control over
capital and service development for “high performing” NHS Trusts (Dixon,
2003; Klein, 2003). Although the extent to which Foundation Trusts will be able
to function independently of the local health community is unclear; this development, and the proposed increase in emphasis on activity based funding,
could reduce PCT scope for manoeuvre and ability to resource communitybased services.
Opportunities for practice-level commissioning are intended to deflect criticism of PCTs as stand-alone purchasers, to produce a layered approach to
primary care purchasing and increase patient and public involvement. Practicebased commissioning, for example, devolves commissioning to individual practices or to small groups that agree to pool their populations and resources. All
practices can participate and receive indicative budgets that take account of
activity levels and health needs. Practices are accountable to the Professional
Executive Committee of the PCT for their commissioning decisions so their
decisions must be justifiable in terms of local objectives. Practice-based commissioning is intended to improve care for patients with common chronic conditions and to help practice teams fund innovation at neighbourhood level
(Department of Health, 2004).
Practice-led commissioning is slightly different from practice-based commissioning. It is closer to fundholding in allowing practices to invest in improved
care if they make savings. However, the adoption of standard prices, the explicit
quality criteria included in the new general practitioner contract, and the financial incentives attached, are intended to focus contract negotiations on quality,
the development of tailored services and to reduce avoidable admissions
(Lewis, 2004).
Nurse-led commissioning is a related initiative (Department of Health,
2004). The development of nurses as purchasers should remove anomalies over
access to community services. Historically, problems have arisen at the boundary between health and social care or health and housing. Here, judgements
about the relative benefit of drug and nondrug treatment (e.g. environmental
assistance or aids to daily living) have been distorted by perverse incentives
associated with the organization and funding of services.
Personal Medical Services pilots
The above reforms emphasized purchasing of specialist services. The evaluation
of total purchasing, however, considered that enhancing primary care provision
was also important (Mays and Dixon, 1996; Wilkin et al., 1999). Eighty-five
Personal Medical Services (PMS) pilots were established in 1998. Further waves
have followed. Single-handed practices can now collaborate in a PMS framework that is the provider equivalent of community fundholding (Honey et al.,
The impact of primary care purchasing in Europe
111
2003). Primary Care Trusts and participating practices can purchase enhanced
primary care and community services tailored to local need. In return for this
flexibility, general practice contracts are managed locally rather than being
nationally held, locally administered contracts.
Spain: the purchaser/provider split in Catalonia
Spain began its primary care reform in the 1980s. Implementation was measured;
areas with lower socioeconomic status were prioritized. Professional education,
medical management and improved salaries underpinned the reforms.
Several aspects of Catalonia’s health care system differ from elsewhere in
Spain. It piloted a purchaser-provider split when the Health Care Organization
Law was passed in 1990 (Llei d’Ordenació Sanitària de Catalunya, or LOSC). This
facilitated integrated care, organizational rationalization and improved regulation in a system in which 60% of beds were owned by private and public
organizations not belonging to the Regional Health Authorities (Regional
Health Department). Similar diversification of provision was implemented in
primary health care. Among the diversified primary care providers a form of
fundholding developed in the mid-1990s with the Entitat de Base Asociativa
(EBA). Here, a team of doctors and nurses receives a budget for a defined population, including salaries, premises, diagnostic tests, specialist referrals and prescriptions. The proportion of the population covered by organizations separate
from the Regional Health Authorities (EBA and other public organizations
linked to municipalities and religious organizations) is growing as implementation of primary care reform continues. In 2003, the EBA provided 14 out of 346
primary care teams. At the end of 2003, 20% of primary care was provided by
teams that are not directly owned by the health department (Institut Català de
la Salut). Although evaluation of this aspect of the Catalan reforms has been
limited, indicators are generally positive. (Violan et al., 2000) Comparison of
socioeconomically similar areas of Barcelona also found that service use, practice indicators, quality and drug costs did not vary significantly between the
different models of primary care provision, although non-public services
employed relatively fewer nurses (Guarga et al., 2000). An external evaluation
found that general quality indicators were similar in different models,
although EBA teams employed fewer nurses, prescribed less drugs, ordered
fewer laboratory tests and referred fewer patients to specialists. On the contrary, health teams managed by non-departmental organizations linked to
municipal-religious or private community hospitals were higher prescribers,
referred more patients to specialists and carried out more laboratory test. The
Institut Català de la Salut was in between the two models (Fundació Avedis Don
Avedian, 2003). The lack of differences on the quality indicators suggests
that the policy of diversifying ownership of the organizations providing
primary health care services promoted competition and benefited the whole
Catalan community and not only the citizens covered by the pilot projects
(Gené-Badia, 2003).
112
Primary care in the driver’s seat?
The Russian Federation and the former Soviet Union
The first experiments with primary care funding in the Soviet Union occurred
in St Petersburg, Kemerovo and Samara between 1987 and 1991 (Tragakes and
Lessof, 2003). Some initially promising findings, for example reductions in
hospital admissions, were not sustained. A combination of ineffectual regulation and the financial crisis of the early 1990s appeared to overwhelm
the health care system, with primary care suffering most (Tragakes and
Lessof, 2003).
Experimentation continues in Samara. Polyclinics are budget holders, providing primary care and purchasing hospital services for a listed population. The
budget is based on a capitation formula and includes financial incentives. If
inpatient costs exceed the budget (there are some exceptions for complex
treatments) the polyclinic must fund the difference. Reform is backed by physician education in primary care, modernization of management and regulation,
active collection of health insurance and protection of payments made on
behalf of the non-working population. In Samara the proportion of the budget
allocated to hospital inpatient care has dropped from 80% in the Soviet era to
around 54% and many polyclinics have developed day facilities.
Despite this progress, concerns remain that funding is insufficient to provide
modern health care. There are suggestions that enhanced services are available
for those able to pay, and additional payments may be requested for services
included in polyclinic capitation payments (Tragakes and Lessof, 2003).
Primary care reform in Finland – a continuum within a country
The Finnish Government Subsidy Reform Act of 1993 changed the way that
health services were funded and turned municipalities (local authorities) into
potential purchasers. The reform enabled municipalities to allocate funds prospectively rather than simply paying for activities that had already been undertaken. At the same time, national taxation became less important; now most
health care is funded from local income taxes, without an earmarked allocation
for health care. Since the subsidy reforms, municipalities have been able to
provide services themselves, with other municipalities, or purchase them from
other public or private sector providers.
Despite the opportunities offered by the subsidy reform, few municipalities
purchase specific services or procedures actively, for example, by specifying
targets, expected levels of activity, or quality. Clinical input into the allocation
of funds to specialist care is similarly limited; in many municipalities even
the role of the chief physician, who should advise the health and social care
board of the municipality about health care provision, is limited to making
changes at the margins. Barely a handful of examples exist of primary care
professionals being actively involved in purchasing. Most of the examples from
Finland that were characterized previously as primary care purchasing, therefore, are actually purchasing by health and social care boards of municipalities
(local authorities).
The impact of primary care purchasing in Europe
113
Health centre purchase of community services
Community services for elderly people as well as residents with mental health
or substance problems are often purchased from small private and not-forprofit providers, including patient organizations. Since Finnish regulations
require that health services delivered by external providers are subject to a
tendering process, health centre chief physicians contribute to the design of
tenders, with active purchasing of services for these patient groups. Municipalities can also supplement their funding by purchasing mainstream services
from not-for-profit organizations. As the profits of the Slot Machine Association (Ray) fund most of the costs and activities of most not-for-profit organizations that provide health-related services, municipalities can purchase care
from them at less than full cost, thus benefiting indirectly from lottery funding
(Myllymäki, 2002).
Purchasing specialist services in primary care
Nilsiä, a rural municipality, provides a typical example of primary care purchasing of specialist services. Primary care holds the budget for health centre diagnostic and treatment services, including a basic laboratory, X-ray facilities and
small in-patient units. Most specialist care, however, requires a 50 km journey
to the regional centre. To improve local access the health centre (through the
chief physician) purchases diagnostic and consultant outreach clinics from the
hospital district and private providers. Examples include cardiology, gastrointestinal endoscopy, and speech therapy. The services purchased, however,
comprise only around 0.2% of the specialist care budget.
Failed attempt to contract for primary and specialist care
Another rural municipality – Liminka – attempted comprehensive purchasing
by tendering its primary and specialist health services (Keisu, 2002). No provider
tendered for primary care and only the hospital district offered comprehensive
specialist care. Subsequently the municipality contracted with the hospital district for specialist care. Based on this tendering exercise, private providers were
more expensive, and purchasing specialist care piecemeal would have increased
transaction costs while reducing annual spending by only 0.5%.
Network-based purchasing
Primary care has greatest influence on specialist services where primary care and
basic hospital services have been integrated into area-based federations. Here,
GPs usually manage the federations and negotiate agreements with the hospital
district and private providers for specialist services on behalf of member municipalities. These federations wield the combined purchasing power of the member municipalities and are more able to purchase and deliver care in line with
114
Primary care in the driver’s seat?
integrated care plans that reflect local health problems (Ministry of Social Affairs
and Health, 2002).
Primary health care purchasing in Estonia: primary care
budgets for diagnostic services and indirect purchasing
Since 1998, family practitioners (FPs – the preferred translation of the Estonian
term for GPs) have undertaken limited fundholding functions. The 2002 virtual
budget, for example, comprised 18.4% of capitation fees to purchase selected
clinical and diagnostic services that were excluded from capitation funding. A
government decree lists the services FPs should purchase: clinical care includes
minor surgery and physiotherapy, while laboratory services include routine
X-rays, more common endoscopic procedures, and biochemical tests. In 2002,
the “budget holding” comprised 3.5 million in total, or 5,000 per FP. FPs
contract with providers of diagnostic services and manage the payments but
cannot retain funds if they under-utilize diagnostic services. If they pay less
than the health insurance list price for services, however, they can retain the
savings. Currently, 5–10% discounts on laboratory tests are available. This initiative is designed to develop negotiation, budgeting and planning skills among
primary care purchasers and laboratory service providers.
Indirect purchasing in Estonia
Involvement in indirect purchasing complements FPs’ fundholding role. FPs
participated in the health insurance fund process for commissioning specialist
ambulatory care services for the first time for the 2002 contracts. Commissioning was limited to the two major urban areas and selected specialties: orthopaedics, ENT, obstetrics and gynaecology, and ophthalmology. The final decisions
reflected cost and quality criteria; FP preferences accounted for 20% of the quality evaluation. These arrangements are still evolving and the health insurance
fund has recognized that expansion of purchasing will require improved
measurement and further strengthening of governance arrangements.
Linking direct and indirect primary care purchasing with
primary care team development in Italy: the Imola project
Italian GPs are gatekeepers but the law forbids them from purchasing treatment
for patients. However, indirect purchasing through policy development and
implementation is widespread and GPs enjoy strategic influence over health
care spending. Drug prescribing and diagnostic tests provide further purchasing
opportunities for GPs. One example is the 1997 demonstration project in Imola
Local Health Unit, near Bologna (Donatini, 2002).
Imola has a population of 106,000 and one hospital. All 87 GPs were organized, voluntarily, and with the support of professional organizations, into nine
teams covering homogeneous areas. The health unit and GPs designed team
The impact of primary care purchasing in Europe
115
objectives to improve quality of care and collaboration. Teams and individual
GPs were offered incentives, including finance and facilities. The implementation process included training around the project objectives and reporting system, clinical guidelines, budgeting, team-based agreements, funding for team
meetings and professional development. GPs were rewarded for achieving project objectives in their own practice. Maximum rewards were received where the
whole team achieved the objective. The project tackled common, important
clinical problems such as hypertension. Here, the aim was to make treatment
more evidence based, producing 1% shifts in the balance of different drug
treatments.
Sweden – failed attempt to introduce primary care purchasing
Primary care has been relatively underdeveloped in Sweden compared with
other countries with tax-based health care systems. In the early 1990s, some
“model” county councils piloted different models of the purchaser-provider
split. In Stockholm and Dalecarlia primary care became part of the purchasing
organization to provide expert support to the commissioning process (Bergman,
1994). Purchasing districts in Stockholm averaged 200,000 inhabitants while
in Dalecarlia they were coterminous with municipal boundaries. District populations averaged 20,000; the smallest had fewer than 10,000 inhabitants. In
Northern Dalecarlia, around Mora district hospital, strategic and collaborative relationships between primary care and hospital specialists improved
and helped to integrate services. This is the only obvious Swedish example of
primary care doctors participating actively in purchasing (Svalander and
Åhgren, 1995).
Primary care no longer purchases specialist services. Political concerns about
lack of separation between the purchasing organization and primary care provision means that county council purchasers now contract with family doctors,
other specialists and hospitals in parallel. Some consider this an improvement;
primary care is more independent of county councils, and has a higher profile.
Alternative attempts are under way to improve collaboration between health
care professionals and to reform primary care.
Comparing theory and practice
To what extent have purchasing arrangements, as discussed in the previous
section, met the expectations of its advocates? This is a difficult question to
answer because of the limited available evidence. Primary care purchasing has
developed furthest in the United Kingdom, the United Kingdom has experimented with models that cover most of the primary care purchasing continuum
and it is here that primary care purchasing has been most widely evaluated. For
these reasons, substantial use is made of United Kingdom evidence but,
throughout, it has been compared and contrasted with evidence from other
countries too.
116 Primary care in the driver’s seat?
Evidence of benefits arising from primary care purchasing
The wider organization of the health service clearly has an influential role in
determining the extent to which it is possible to devolve budgets to primary
care. There is no evidence, however, that a simple relationship exists between
the degree to which purchasing initiatives achieved their objectives, the type of
purchasing undertaken, and the previous influence of primary care in the
health system. Many of the benefits result from opportunities available to primary care purchasers to accelerate the implementation of improvement processes, such as review of prescribing patterns that were already under way. The
evidence of the benefits of primary care purchasing can be summarized as
follows.
1. Organizational improvement
• Reduced isolation among small practices, facilitating alliances between GPs,
•
•
respecting single-handed practice while providing the organizational and
financial advantages of joint working.
Cases: Community fundholding (United Kingdom), some PMS initiatives and
Imola network (Italy).
Increased resource allocation and commitment to organizational development in primary care.
Case: Total Purchasing Pilots and Primary Care Trusts (United Kingdom).
Primary care reform programme aligned with devolved budgeting.
Cases: Estonia, Italy, Spain.
2. More flexible service provision
• Expanded range of services in primary care.
• More responsive services – timelier access, test results, electronic communication.
Cases: United Kingdom – fundholding, commissioning, TPP, PMS pilots,
Estonia, Finnish GP Federations, Sweden.
3. Quality of care
• Increased
adherence to laboratory guidelines, reducing blood tests by
approximately 8% and reducing hospitalization for ambulatory care sensitive
conditions like diabetes by 6%.
Case: Italy – Imola.
4. Improved cost-effectiveness of care
• Limited evidence but linked to availability of financial or professional incentives encouraging, for example, cost-effective prescribing.
Cases: United Kingdom – fundholding, commissioning, PCG, PCT, Italy,
Imola.
5. GP as the patient’s agent
• No evidence that fundholders reduced referrals inappropriately, some made
wider use of the private sector.
The impact of primary care purchasing in Europe
•
•
•
•
117
Case: United Kingdom – fundholding and commissioning, Estonia, preliminary results.
Purchasing used to bypass bottlenecks and reduce waiting times.
Case: Finland.
Fundholders and commissioning GPs used extra information about clinical
and organizational quality of specialist services to help redesign and reprovide
services.
Cases: United Kingdom – fundholding and commissioning.
Imola and Samara projects improved population coverage of primary care.
Cases: Italy, Russian Federation.
Tentatively positive results from changes in the primary care environment.
Cases: Estonia, United Kingdom PMS for underserved populations.
6. Increased influence for primary care
• Short feedback loop and budgetary control provided leverage over specialist
care and more active management of the interface between primary and
secondary care.
Cases: United Kingdom – Total Purchasing Pilots, Sweden – Dalecarlia pilot,
Finland – specialist care in reach and primary care federations, Spain –
Catalonian primary care reform.
Problems with the implementation of purchasing
Problems associated with devolved budgeting initiatives include a mixture of
foreseeable and unforeseeable adverse consequences of implementation undertaken as planned, as well as subverted, incomplete or unsuccessful
implementation.
1. Management and transaction costs
• Decentralization
of purchasing, invoicing, processing and monitoring of
small contracts and active GP involvement in increased management and
transaction costs, 85% of management costs incurred at practice level in TPPs.
Cases: United Kingdom – most obvious in fundholding and TPPs, but GP
time commitment also heavy in commissioning.
2. Direct or indirect financial risk and perverse incentives
• Evidence
•
•
of indirect risks, for example, reduced ability to purchase care
because of specialist services overspending, funding cuts, limited control over
specialist referrals because of weak gatekeeping or care coordination.
Cases: Finland, Russian Federation, Sweden.
Theoretical direct risk of income reduction following ‘inappropriate’ purchasing decisions. In practice, risks were limited where primary care provision
received dedicated funding, risks limited to additional income, or ‘borrowing’
from one year to the next allowed.
Cases: Estonia, Italy – Imola, United Kingdom – fundholding.
Focus on cost of laboratory tests rather than quality, for example the reliability of results, may encourage family practitioners to contract with services
118 Primary care in the driver’s seat?
that use cheaper but less appropriate methods of analysis or laboratories with
poorer control systems.
Cases: Estonia, United Kingdom – fundholding.
3. Governance
• Lack
•
of effective sanctions on fundholder overspending despite impact on
contracts for non-fundholding practices and squeeze on management
resources for developing non-fundholders.
Case: United Kingdom.
Professionals may protect their income at the expense of necessary referral,
comprehensive service provision and maintaining ethical standards.
Case: Russian Federation.
4. Adverse impact on equity
• Trend
•
towards shorter elective waits, more consultant outreach, and wider
range of service models in fundholding and PMS practices rather than availability being directly related to need. Not found in Catalonia because equity
explicitly built into strategy.
Opportunities for active purchasing, and the service improvements that
resulted from tackling bottlenecks in service provision, for example, were
possible because of the competence of specific individuals; availability was
unrelated to the level of health need and the opportunities of individuals to
use alternative services.
Cases: PMS, United Kingdom – fundholding.
5. Lack of strategic focus
• Certain conditions emphasized over others, e.g. elective surgery over chronic
•
•
•
conditions, little evidence of anticipated change of focus from demand to
population needs assessment and longer-term development.
One-year contracts may allow some purchasers (particularly those in urban
areas) to disengage from dysfunctional providers but do not provide the stability or the incentives necessary to encourage service redesign or longer-term
development.
Emphasis on current activity and intervention fails to take account of the
importance of teaching and research for future patients.
Cases: Sweden, much of United Kingdom – fundholding.
Factors associated with the failure of primary care purchasing
to develop
The health systems of countries that have failed to develop primary care purchasing and devolved budgeting share several characteristics. These may be
considered under four headings: alignment of policy and practice; consensus
about the role and objectives of primary health care; the primary care infrastructure and operational environment; and financial risk.
The impact of primary care purchasing in Europe
119
Alignment of policy and practice
Devolving budgets to primary care, empowering primary care purchasers and
developing a primary care-led service requires direction of policy, resources and
professional expertise towards the same objectives. In the United Kingdom,
national and local primary care organizations shaped purchasing reforms. Individual champions were complemented by an influential primary care presence
in the health care system. Similarly, the long-standing alliance between
politicians, professionals and the public in Catalonia, and the creation of
co-operative stakeholder relationships in Imola provide one explanation of why
reform flourished in these settings. The contrast between cases that illustrate
relatively successful and limited implementation of devolved budgeting highlights the importance of professional and political relationships, misaligned
policies and organizational factors.
Role and objectives of primary care
The limited implementation of devolved budgeting in Sweden illustrates the
failure to clarify the objectives of the initiative, or to address issues such as the
GP’s role in gatekeeping and coordination of continuing care before purchasing
was established. This implies limited consensus between stakeholders about
their responsibilities (Delnoij and Brenner, 2000). Specifically, neither the role
of general practice nor the involvement of primary care professionals in the
development of health policy and strategy at local level were agreed (Svalander,
1999). This became clear when the key players took positions that limited the
potential of primary care purchasing. Politicians perceived that having primary
care purchasers blurred the distinction between the politicians’ and officials’
strategic role and the doctors’ responsibility for day-to-day health care. Hospital
staff worried that, as purchasers, primary care leaders would have greater access
to politicians and officials, and thus would receive preferential allocation of
resources. GPs held the opposite view, fearing that they would be forced to take
financial responsibility for decisions made without their involvement, and that,
being close to those who set their budgets; it would be easy for primary care
funding to be squeezed.
Infrastructure and operational environment
The power of primary care as a potential purchaser was also weakened in
Finland and Sweden by changes to the infrastructure and operational environment that facilitated the development of alternative primary care providers. In
Finland, the economically active population is encouraged to use workplace
services, and visits to private specialists are partly reimbursed by the social
insurance institution. While this weakening of the role of the primary care
doctor was probably unintended in Finland, competition was an explicit policy
objective in Sweden, particularly in Stockholm. It is difficult for primary care to
provide a strategic lead in a health system in which primary care providers
120 Primary care in the driver’s seat?
compete with each other, and with ambulatory care services. In contrast, separation between the GP as primary care doctor and the individual doctor’s strategic role in purchasing organizations has enabled GPs in the United Kingdom
to remain purchasers and providers.
Neither the United Kingdom nor the Catalonia experiments suggest that tendering for services is the main obstacle to purchasing. Rather, the problem
relates to limitations in the GP’s role as gatekeeper and coordinator of care for a
designated population. Population-based information about health, disease,
health service use, and patient preferences are essential if primary care staff are
to base purchasing decisions on evidence. Life long patient records complement
population information, providing the link between purchasing decisions for
individuals and populations, and the detail necessary for managing care across
organizational boundaries. From the utilization review perspective, clinical
records provide the evidence required to challenge provider assessments of
co-morbidity and limit Diagnosis Related Groups (DRG) creep. In countries
where patients can choose their provider by episode, comprehensive records are
rare. Where register systems are employed as alternatives, for example in Finland
and Sweden, the register fields may limit the information available. This restricts
the GP’s role as patient agent, care coordinator, and informed purchaser.
The organizational environment, particularly the extent to which policymaking is shared within the health care system, is also important. In Finland,
devolved budgets enabled some Finnish health centres to introduce more
patient-friendly services. However, GPs in individual health stations (the
equivalent of a group practice in the United Kingdom) are rarely consulted over
purchasing decisions. Being the agent of the collective patient, therefore, is a
struggle. The Finnish case and the problems highlighted in the Russian Federation experiments illustrate the need to establish the GP’s role as the patient’s
agent before introducing purchasing.
Financial risk
Some commentators have suggested that primary care purchasing in the United
Kingdom would have been more successful if GPs had borne greater financial
risks. Conversely, the cases studied here suggest that the ability to make choices
about financial risk taking and to control the size of the risk are more important
arbiters of primary care professionals’ behaviour. Scrutiny of other United Kingdom initiatives, for example, suggests that GPs (at least the early adopters) have
been willing to sacrifice income or time for service improvements in which they
believed. For example, many GPs have undertaken more minor surgery or
anticipatory care than that for which they were reimbursed. While threats to
organizational budgets may have accelerated changes in practice, the financial
risks associated with purchasing and innovations have been smaller than those
related to purchasing premises or establishing a professional practice in the
United Kingdom.
These direct risks, however, have been within primary care’s span of control.
Purchasing has foundered, however, where there is a perception of uncontrolled
financial liability. Where primary care staff’s core income has not been
The impact of primary care purchasing in Europe
121
protected, for example in the Russian Federation, imperatives to cut costs and
maximize income to ensure personal security and organizational survival seem
to override those associated with enhancing quality. In contrast, financial risks
associated with most devolved budgeting initiatives have related to additional
or organizational income.
In a more modest way, the reluctance of Stockholm GPs to embrace purchasing
reflected concerns about liability for financial risks that they could not control.
Examples include their limited influence over patient use of specialist services
resulting from the lack of GP gatekeeping. Similar reservations about expanding
purchasing in Estonia reflect family practitioner concerns about taking responsibility for prescribing budgets before funding flows reflect optimal treatment of
common, chronic diseases in primary care. At the same time, however, Estonian
FPs have expanded the care they provide to children in line with professional and
national priorities (Maaroos and Meiesaar, 2004). This illustrates the potential
conflict between policy-makers and politicians, whose main reason for introducing primary care purchasing may be ideological, and GPs, whose motivation
is likely to combine a wish to improve health care and their own status.
Assessing the impact of primary care purchasing across Europe
The evidence outlined in this chapter illustrates a continuum of primary care
purchasing: from the comprehensive purchasing found in the United Kingdom,
Catalonia and Finland to the indirect influence and limited active purchasing
found in Estonia and Bologna. Across this continuum, purchasing experiments
have provided examples of innovation and changes in practice.
Primary care purchasing seems to facilitate modest but important improvements resulting from change at the margin. The establishment of fundholders
as small-scale purchasers could facilitate the shift of services to alternative providers without destabilizing the funding base of local specialist services. Fundholders and commissioning groups could also provide more detailed evidence
of quality problems than was available to the health authority through routine
data collection.
Evidence from the cases suggests that primary care purchasing can act as a
lever to streamline decision-making, improving the flexibility, timeliness, and
appropriate use of diagnostic services. Where appropriate incentives and regulatory mechanisms exist, prescribing may also become more cost-effective. The
alignment of incentives with the objectives of the various stakeholders is crucial. While the Imola project achieved most of its goals, delivering savings,
higher quality care, and improving population coverage of treatment, attempts
at more complex changes in the organization of primary care were less successful. The level of intensive home care, for example, did not increase significantly,
and only just over a quarter of GPs (11 of 41) extended their opening hours.
Success, therefore, requires the ability to combine clinical and financial
decision-making and to ensure that financial strategy and spending reflects
agreed clinical policy and best clinical practice. It seems unlikely; therefore, that
purchasing will develop in health systems in which retrospective reimbursement of specialist services predominates.
122 Primary care in the driver’s seat?
The purchasing of primary care and community services in Finland has led to
more widespread changes in practice than purchase of hospital services. This
also suggests that effective purchasing is unrelated to its complexity; these
community services require detailed agreements to ensure that patients’ needs
are met adequately and appropriately. This finding confirms, however, that
where purchasers have flexibility and a short feedback loop, it is possible to
tailor services more closely to patients’ needs.
The achievements of devolved budgeting illustrate the benefits of approaches
that involve marginal shifts, incremental improvements and well-chosen
incentives. At the level of care groups, clinical directorates or teams, very small
changes in investment patterns can achieve modest but important improvements. Centralized health authority-style financial management finds change
like this difficult. It may be the ability of Finnish purchasers to effect modest but
important changes in investment patterns in primary care and community services, and organizational constraints on doing so for hospital services, which
explains the relative effectiveness of purchasing in some settings, and its failure
in others.
The Finnish example also provides a limited example of a wider move to link
devolved budgeting initiatives to the integration of care for patients with
chronic conditions across organizational boundaries. These approaches may
have been successful because they enable management theories about devolved
budgets to be adapted to fit current theories about clinical practice. The latter
include examples of how best to manage primary care demand and acute
illnesses within a framework that recognizes the prevalence of chronic disease
and the co-morbidity experienced by frequent users of health services.
At a system level, optimizing the balance between encouraging innovation
with tools such as devolved budgeting while minimizing the bureaucracy
associated with maintaining equitable access and service provision requires
careful management. There is some evidence that Primary Care Groups (PCGs)
helped extend the apparent benefits of fundholding and commissioning to a
wider group of practitioners and patients in the United Kingdom. PCGs were
also more democratic organizations. Their elected GP leaders were often chosen
for their motivational and negotiation skills. In part, these personal characteristics, the availability of peer information, feedback and educational support
limited the potential for free riding by less interested GPs and the dilution of
accountability often found in larger organizations. Primary Care Trusts are even
larger, designed as complex networked organizations with employed staff, professionals with portfolio contracts and independent contractors providing a
mixture of purchasing and provider functions. These are potentially dynamic
organizations but in a large organization like the NHS the temptation to create
new bureaucracies is always present. Many PCTs have recognized this risk,
retaining smaller locality developed during the 1990s, and establishing mechanisms for involving local people in decision-making. (Wilkin et al., 2001;
Honey et al., 2003). The relatively smooth transition between organizational
forms in the United Kingdom and Spain reflects the detailed attention given to
planning and implementation. Without such planning, the tension between
flexibility, responsiveness and order may result in unrestrained market conditions replacing centralized structures, as in the Russian Federation, or, as in
The impact of primary care purchasing in Europe
123
neighbouring Finland, may produce little increase in flexibility or empowerment and no reduction in bureaucracy.
Despite the mixed picture from the evaluation of commissioning groups
(Smith and Shapiro, 1996) and fundholding, positive results from purchasing
experiments across Europe reflect the endeavours of a small group of skilled,
enthusiastic, influential professionals (and occasionally politicians). These
innovators share clear objectives, a commitment to improving services for
local people and the opportunity to effect flexible solutions. Sustainable
benefit from devolved budgeting, however, requires primary care professionals
to look beyond immediate problems and to develop strategic activities such
as health needs assessment, service and programme review. The most successful examples in the United Kingdom and elsewhere have been supported
by public health and other strategic expertise. In Bologna, Catalonia, and
more recently in Estonia, the purchasing experiments have formed part of
an explicit regional strategy, supported by detailed objectives and incentives, underpinned by infrastructure development including clinical and
organizational governance.
Contextual preconditions for primary care purchasing
The organizational and professional factors associated with successful implementation of primary care purchasing appear to cluster. This suggests that
effective primary care purchasing requires the presence of certain organizational
and professional conditions.
Organizational factors include a supportive environment that facilitates
needs-based purchasing, ongoing responsibility for care, and a clinical, financial
and managerial framework within which strategic and operational purchasing
decisions may be evaluated. Specific features include:
• designated population based on residence or registered list;
• gatekeeping – non-emergency specialist care based on referral
•
•
•
•
•
by organization with budgetary responsibility;
ongoing responsibility for care;
lifelong clinical records – shared by clinical teams across organizations;
well-established budgeting system with independent oversight;
sound systems for independent clinical review and opportunity for development of more comprehensive clinical governance;
incentives that reward organizational and clinical innovation and
improvement.
Professional factors associated with successful purchasing are based on wider
recognition of primary care expertise (Audit Commission, 2002; Iles and Sutherland, 2002). These include:
• primary
•
care doctors’ education meets international standards for primary
care specialists;
primary care professionals and supportive managers are developed into
competent purchasers (Hallin and Siverbo, 2001);
124
Primary care in the driver’s seat?
• established primary care role includes negotiation with patients, specialists
and managers about individual cases and service developments;
• dedicated time and resources for purchasing activities;
• primary care research infrastructure with support, for
•
•
•
example, for patient
profiling and more formal needs assessment;
ethical and professional framework regulates behaviour;
clear contractual separation between provider and purchasing/strategic role;
strong primary care identity with primary care trusted to provide most clinical
care.
In comparison with the evidence of successful initiatives associated with
devolved budgets, problems have existed where some or all of the preconditions
for effective purchasing were not established in advance and where few professional, managerial or regulatory controls existed.
In Finland, for example, there is little evidence that primary care practitioners
experienced increased authority following the reforms outlined in this chapter.
Loss of dedicated budgets and new responsibilities dissipated the management
efforts of chief physicians who now compete for resources with other areas of
municipal spending and hospital specialties. With their own budgets being cash
limited and without the budgetary influence over specialist care enjoyed in
other countries, the power of primary care professionals may have actually
diminished. At local level, however, there is some cause for optimism. Demonstration projects, most notably the GP-led federations, have enhanced the
position of primary care, enabling local services to position tertiary care in a
supportive rather than a dominant role.
The Finnish example illustrates that transferring budgetary responsibility
without discretion over the nature of care purchased does not enhance the role
or prestige of primary care. Primary care fares well if directly funded separately
from hospital care. Without dedicated funding, however, secondary care tends
to dominate regardless of organizational arrangements.
An increased emphasis on primary care requires more than devolved budgeting. Additional elements include a supportive policy environment, facilitative management, and leaders with well-developed skills in effecting change.
Clearly, market mechanisms have a limited role in health systems that value
cost control, collaboration between purchasers and providers, and equitable
service provision. Injudicious use of market mechanisms may actually reduce
the likelihood of successful purchasing by removing tools like gatekeeping,
lifelong records, and defined populations leading to weaknesses in education,
training, regulation and in governance being overlooked. Instead, active
stakeholder involvement and agreed procedures for determining investment
priorities are required, backed by well-targeted incentives, sanctions and peer
pressure (Robinson and Steiner, 1998; Killoran et al., 1999).
Few countries, however, fulfil all the preconditions for successful purchasing.
The limited evidence base also poses problems for countries considering the
development of primary care purchasing, and the optimal size of the purchasing
organization is also unclear. Specifically, the available evidence does not reveal
the most effective mix of flexibility, short feedback loops, sensitivity to locality
needs, limited transaction costs and equity of service provision. The evidence is
The impact of primary care purchasing in Europe
125
also heavily weighted towards doctors as clinical purchasers; there is little
precedent for the “nurse as purchaser” initiative proposed in England although
there are some lessons to be learned from the social care literature (Murphy,
2004).
Alternative developments designed to enhance primary care
Several of the cases illustrate that it is possible to change the perception and
position of primary care; budgetary freedoms may have facilitated this outcome.
Primary care purchasing exists within a broader organizational approach that
emphasizes the role of devolved decision-making, with primary care teams
responsible for framing the problems their patients face and for designing ways
of addressing them. Purchasing specialist care, however, is only one of the tools
available to deliver improvement.
Most current and future initiatives now focus on the development of
integrated care.
Traditional health service approaches to problems of finance or quality, such
as structural reform, have limited effectiveness as a tool for organizational
development; sustainable change requires more sophisticated approaches
(Walshe et al., 2004).
Most of the evidence suggests that performance reflects competent management and clinical leadership rather than the size of population served (Bojke
et al., 2001).
The attempt to match structure to objectives lies behind the preponderance of
initiatives that focus on developing integrated care, networking organizations
and devolving funding and responsibility. Recent and planned reforms in
Finland, Sweden (Borgquist and Lind, 1997), and the United Kingdom encourage developing networks of cooperation in primary care and across ambulatory
and specialist care. Within a primary care-led health service, such organizations
should facilitate development of leadership and system-level thinking at local
level. In Sweden, devolving responsibility for drug costs in primary and ambulatory care to county councils and piloting integrated drug budgets (Läkemedel i
förändring, 2001), encouraging ‘proximity health care’, increasing the number
of GPs and improving their specialist training (Prop., 1999/2000: 149) demonstrates the commitment to organizational development. In Västmanland
County Council, 40% of GPs are now independent contractors, funded by the
county council and supported by strong multi-professional teams. Here, 80% of
inhabitants have an ongoing relationship with an ‘own GP’. This is almost twice
the national rate of 42% (Socialstyrelsen, 2002). Within this development
framework, some elements of purchasing may be returning. In the southern
district of Stockholm all health centres have been contracted out through a
tendering process. Independent hospitals (private and public) may also be able
to tender to run health centres. Hospitals, therefore, may become primary care
purchasers. These are ambitious proposals, reflecting increased acceptance of
the benefits of integrated care and the management theories that combine
empowerment of local professionals with development of agreed programmes
of care.
126 Primary care in the driver’s seat?
The development of networked organizations will require even more sophisticated support, regulatory mechanisms and resource allocation. Specifically,
information from patient profiles, actual and expected activity and costs, based
on current best practice, should be built into budgets at programme and health
system levels. Assumptions will need to be stated explicitly and tested regularly
to minimize the risk of new perverse incentives becoming established and
distorting practice.
Current thinking views health services as a complex adaptive system. Here,
the role of health care reform is to create the optimal balance between order and
chaos and allow excellence to emerge. It remains to be seen whether the networked approaches that are developing in many health systems will be any
more successful in enabling health services to perform at an optimal level. At a
national level, this also places responsibility on governments to ensure that
the future structure and organization of health services, and local and national
policies are compatible, supported by economic and social development and
environments that empower staff and patients.
Notes
1
2
Spanish documents summarized and translated by Joan Gené-Badia for this section:
Violan et al. (2000), Guarga et al. (2000), Fundació Avedis Don Abedian (2003), and
Gené-Badia (2003). The authors are also grateful to Andrea Donatini for helping to
find the Bologna case and for providing contacts.
Arrangements governing primary care purchasing differ somewhat between England,
Northern Ireland, Scotland and Wales. The systems described in this case study apply
to England; some, but not all of them, apply to the other countries.
References
Allsop, J. (1995). Health Policy and the NHS: Towards 2000. London: Longman.
Audit Commission (2002). A Focus on General Practice in England. London: Audit Commission (http://www.audit-commission.gov.uk/publications/genprac.shtml, accessed 22
July 2002).
Bergman, S-E. (1994). Purchaser-Provider Systems in Sweden. Spri tryck 250.
Bloor, K., Maynard, A. and Street, A. (1999). The Cornerstone of Labour’s “New NHS”: Reforming Primary Care. Discussion paper No. 168. York: University of York, Centre for Health
Economics.
Bojke, C., Gravelle, H. and Wilkin, D. (2001). Is bigger better for primary care groups and
trusts? British Medical Journal 322: 599–602.
Borgquist, L. and Lind, J-I. (1997). Förnyelse i sjukvårdssystem – kvalitetsaspekter och
besparingspotentialer vid verksamhetsförändringar [Renewal in health care systems –
aspects on quality and potentials of saving when changing the activities], Kommunal
Ekonomi 5: 21–23.
Delnoij, D.M.J. and Brenner, G. (2000). Importing budget systems from other countries:
what can we learn from the German drug budget and the British GP fundholding?
Health Policy 52: 157–169.
Department of Health (2004). Practice Based Commissioning Engaging Practices in Commissioning. London: The Stationery Office (http://www.dh.gov.uk/assetRoot/04/09/03/
59/04090359.pdf, accessed 1 December 2004).
The impact of primary care purchasing in Europe
127
Department of Health (1997). The New NHS: Modern, Dependable. London: The Stationery
Office.
Dixon, J. (2003). Foundation trusts, British Medical Journal 326: 1344–1345.
Donatini, A. (2002). Personal communication.
Fundació Avedis Don Abedian (2003). Avaluació de la reforma de l’Atenció Primària i de la
diversificació de la provisió de serveis [Evaluation of primary health care reforms and
diversification of service provision]. Barcelona: Fundació Avedis Don Abedian.
Gené-Badia, J. (2003). Todos los ciudadanos se han beneficiado de la política de deiversificación de la gestión de atención primària en Cataluña [All citizens benefited from
primary care management diversification in Catalonia], Cuadernos de Gestión para
el Profesional de Atención Primaria 9(3): 117–119.
Glennerster, H., Matsaganis, M., Owens, P. and Hancock, S. (1994). Implementing GP
Fundholding. Buckingham: Open University Press.
Gould, M. (2004). Merger pressures on primary care threaten to blur local focus, Health
Service Journal 114: 10–11.
Guarga, A., Gil, M., Pasarín, M., Manzanera, R., Armengol, R. and Sintes, J. (2000). Comparación de equipos de atención primaria de Barcelona según formulas de gestión,
Atención Primaria, 26: 600–606.
Hallin, B. and Siverbo, S. (2001). Jakten på den goda styrningen [The hunt for the good steering].
Gothenburg: Centre for Analysis of Health Care (CHSA).
Honey, S., Small, N. and Walsh, M.J. (2003). Being a GP in a Primary Care Trust.
Nuffield Portfolio Report No. 20. Leeds: Nuffield Institute for Health (http://
www.nuffield.leeds.ac.uk/downloads/being_a_gp.pdf, accessed 12 October 2004).
Iles, V. and Sutherland, K. (2002). Managing Change in the NHS. Organisational Change: A
Review for Health Care Managers, Professionals and Researchers. NHS Service Delivery
and Organisation (SDO) Research and Development Programme. London: NCCSDO
(http://www.sdo.lshtm.ac.uk/publications.htm, accessed 1 September 2002).
Keisu, M. (2002). Tarjouskilpailu Limingan terveyspalveluista [Tenders for Liminka health
services]. Paper presented at a seminar on competitive tendering from a social and
health policy perspective, organized by the National Centre for Research and
Development in Social Services and Health.
Killoran, A., Mays, A., Wyke, S. and Malbon, G. (1999). Total Purchasing. A Step Towards
New Primary Care Organisations. London: King’s Fund.
Klein, R. (2003). Governance for NHS foundation trusts, British Medical Journal 326:
174–175.
Läkemedel i förändring [Pharmaceuticals in alteration] (2001). News letter from Federation of County Councils, No. 18 (http://www.lf.se/lakemedel, accessed 22 July
2002).
Lewis, R (2004). Practice-led Commissioning. London: King’s Fund.
Maaroos, H-I. and Meisesaar, K. (2004). Does equal availability of geographical and human
resources guarantee access to family doctors in Estonia? Croatian Medical Journal 45:
567–572.
Mays, N. and Dixon, J. (1996). Purchaser Plurality in UK Health Care. London: King’s Fund.
Ministry of Social Affairs and Health (2002). National project on securing the future of Finnish
health care. Proposed actions for the renewal of the functional and administrative structures
of the service providing system. Working Group report. Helsinki: Ministry of Social Affairs
and Health.
Murphy, E. (2004). Case management and community matrons for long term conditions,
British Medical Journal 329: 1251–1252.
Myllymäki, A. (2002). Kansalaisjärjestöt palvelujen tuottajina ja raha-automaattiyhdistyksen
tuki [Citizen organizations as service providers and Slot Machine Association funding].
Paper presented at a seminar on competitive tendering from a social and health policy
128 Primary care in the driver’s seat?
perspective, organized by the National Centre for Research and Development in
Social Services and Health.
Prop. 1999/2000: 149 (1999/2000) Nationell handlingsplan för utvecklingen av hälso- och
sjukvården. [Governmental proposal for a national plan for development of health
care.]
Robinson, R. and Hayter, P. (1995). Reluctance of general practitioners to become fundholders, British Medical Journal 311: 166.
Robinson, R. and Steiner, A. (1998). Managed Health Care. Buckingham: Open University
Press.
Smith, J. and Shapiro, J. (1996). Holding on While Letting Go. Birmingham: Health Services
Management Centre.
Socialstyrelsen (National Board of Health and Welfare) (2002). Nationell handlingsplan för
hälso- och sjukvården. Årsrapport 2002 [National plan for health care. Yearly report 2002].
Stockholm: National Board of Health and Welfare.
Svalander, P-A. (1999). Primärvården inför framtiden [Primary health care in the future].
Stockholm: Landstingsförbundet.
Svalander, P-A. and Åhgren, B. (1995). Vad skall man kalla det som händer i Mora? – och
andra frågor om styrmodeller. En preliminär uttolkning av fallstudier i sex landsting [A
preliminary interpretation of case studies on steering models in six county councils]. Rapport
till HSU 2000. Stockholm: Landstingsförbundet.
Taylor, D. (1991). Developing Primary Care: Opportunities for the 1990s. London: King’s Fund
Institute.
Total Purchasing National Evaluation Team (1997). Total Purchasing: A Profile of National
Pilot Projects. London: King’s Fund.
Tragakes, E. and Lessof, S. (2003). Health Care Systems in Transition: Russia. Copenhagen:
WHO (http://www.euro.who.int/document/e81966.pdf, accessed 3 December 2004).
Violan, C., Elias, A. and Ponsà, J.A. (2000). El modelo catalán de atención primaria [The
Catalonian Primary Care Model], Cuadernos de Gestión para el Profesional de Atención
Primaria 6: 43–47.
Walshe, K., Smith, J., Dixon, J., et al. (2004). Primary care trusts, British Medical Journal 329:
871–2.
Wilkin, D., Gillam, S. and Coleman, A. (2001). The National Tracker Survey of Primary
Care Groups and Trusts 2000/2001: Modernising the NHS? Manchester: University of
Manchester.
Wilkin, D., Gillam, S. and Leese, B. (eds) (1999). The National Tracker Survey of Primary Care
Groups and Trusts: Progress and Challenges 1999/2000. Manchester: University of
Manchester.
chapter
seven
The evolving
public-private mix
Rod Sheaff, Joan Gené-Badia,
Martin Marshall and Igor Švab
Conceptual framework
Policy change in Europe after 1990 involved a variety of shifts from public to
private health care provision, especially in the countries of central and eastern
Europe (CEE). This chapter takes a broader perspective than others in this
volume, reviewing how the public-private mix has changed not just in primary
care but also in the more general area of primary health care, among the
mechanisms that coordinate what is a broad mix of related activities.
PHC can be defined as health care which a person can access directly (not via
intermediaries) and use while still living at home (Sheaff, 1998). Its backbone is
primary care medicine (general practice or the equivalent) but it also includes
domiciliary care, paramedical services, pharmacies, workplace health care, selfhelp, emergency services, ambulances and direct-access hospital outpatient
clinics. Before 1990 European health systems were conventionally classified as
Bismarckian, Beveridge or Semashko types. Bismarckian systems funded private, charitable and public health care providers through an employment and
income-based system of compulsory subscription to not-for-profit sickness
funds. In Beveridge systems the national, regional, and/or municipal government owned and managed most health care providers, funding them from
general taxation. Semashko systems differed mainly in not permitting private
practice alongside public practice, as well as its normative-based system of
planning and management (Yugoslavia was an exception – see below). Switzerland never formally adopted the Bismarckian system but a combination of
sickness fund and private insurance, subsidies and regulation attained 98%
population health care insurance cover by 1990. Furthermore, health systems
often mixed these different models. In Spain, for example, general practice
operated partly on the Beveridge model with GPs doing 2.5 hours a day
130 Primary care in the driver’s seat?
consultation in public clinics, but seeing insured and private patients outside
those hours.
Coordination of public and private health care providers occurs – or fails to –
at three levels. One is the national “macro” level. At the second, subnational
(“meso”) level, health care organizations with a planning and/or financing
function exist either at regional (Canton, Land, Departement, Oblast) or at district (e.g. municipality) level. As the third level, providers, including individual
free professionals, are the “micro” level of analysis. Despite the term “micro”
some primary care providers can be quite large (for instance, health centres in
Scandinavia, Portugal and Spain). Primary care providers fall into four categories. Semashko and Beveridge systems have traditionally relied on public
providers directly line-managed by governmental bodies. An important health
system development has been the management of some primary health centres
as “public firms”, publicly owned but with similar managerial autonomy to a
private firm (see below). Not-for-profit providers range from charities to large
institutions which do not distribute dividends to shareholders but in many
other respects behave as commercial bodies (e.g. BUPA). Purely private (e.g.
for-profit) bodies are the remaining category. It includes commercial firms;
however, individual self-employed doctors, or partnerships of doctors, are the
commonest form.
The situation before 1990
Before 1990, macro-level coordination of public and private provision occured
in a rather negative way in Beveridge systems. Law and regulation demarcated a
division of labour between public and private providers. In the few matters
where the law, regulation or contract were silent, the public system was not
obliged to provide services but private providers could. For English GPs, for
example, certifying deaths was NHS work, but certifying health for insurance
purposes was private work for which patients would pay the GP. Private practice
was regulated by the general legal system and any contracts through which
public bodies purchased services from private providers.
Bismarckian systems used two main means of coordinating independent
practitioners with the sick funds, the health ministry and other providers. Regular negotiations took place between sick funds, primary care providers, the
government and, on occasions, other interested parties (e.g. pharmaceutical
firms). In West Germany these discussions were routinized as a permanent institution. Coordination was also achieved by setting common terms, prices and
conditions for GP contracts, whether at national (e.g. France, the United Kingdom) or meso level (e.g. the Netherlands, West Germany). Whatever the standard
contract did not prohibit was open to conventional private practice.
Superficially, macro-level coordination was simple in Semashko systems.
Their principles were universal coverage and equal access for the whole population. There was little room for independent practitioners, or voluntary and
charitable health care providers. During a transition period after 1945 GPs were
allowed to work in existing health centres or premises that they had previously
owned, but as public employees receiving a salary from the state. As the state
The evolving public-private mix
131
rapidly built further health centres and polyclinics, these physicians were
forced to work there under similar conditions to other salaried employees. The
exception was Hungary, where the state built few polyclinics but allowed
independent practice throughout the communist period. GPs were allowed to
work outside regular hours as independent practitioners (Švab et al., 2000).
During the “years of stagnation”, illegal private practice (under-the-table
payments, bribes, etc.) was ignored in official policy but in reality increasingly
tolerated. For senior officials (including health managers) separate nomenklatura
services also operated (particularly in the USSR), somewhat analogously to
private health care in the west. Certain occupations also had separate health
services: military and security services, railway and telecommunication
workers (Poland) and airline workers (USSR). These parallel systems included
primary care.
For Semashko systems, meso-level coordination between the nomenklatura
and other parallel services and mainstream services was weak. Although private
practice was legally forbidden in most communist countries, meso-level authorities silently tolerated some forms of it. Physicians received low salaries, leading
to low levels of service and to physicians seeking private income, often through
informal payments or illegal practice. For example, in the former Yugoslavia,
private dental practice flourished and was known to exist by everyone even
though it was legally forbidden. It was quite often run in dentists’ homes after
working hours for patients who could afford out-of-pocket payments (Švab
et al., 2001).
In all three systems, where the same individual did public and private work,
the two were coordinated by “fitting in” private work whenever public sector
duties allowed. In Bismarckian systems, general practices could subcontract
other private providers to undertake, say, out-of-hours cover or paramedical
services. Where voluntary and charitable bodies filled gaps in the public service
provision (e.g. by providing “hospital-at-home”, family planning or hospice
services), public and private services were coordinated through referral paths.
Beveridge systems also coordinated services by managerial direction.
The Yugoslav system was based on Andrija Štampar’s (former President of the
Yugoslav Academy of Sciences and Arts) ideas which, although socialist, differed
from the Semashko system. Štampar’s model emphasized meeting population
health care needs through doctors working in the community in close contact
with local authorities. Health centres were local hubs for delivering health care,
health promotion and prevention. General practice was always considered central, but community nursing was also valued. However, a range of specialist
services were introduced after 1950, making health centres very similar to
Semashko-style polyclinics, especially in big cities (Zarkovic et al., 1994; Švab
et al., 2000).
Different health system architectures accommodate different forms of
provider, and therefore a different public-private mix, although there is no
simple one-to-one correspondence between provider mix and health system
architecture.
The main medical care providers in Bismarckian and some Beveridge systems
(the United Kingdom and Denmark) were self-employed doctors contracted to
the state or to sickness funds but also permitted to undertake private practice
132
Primary care in the driver’s seat?
and commonly doing so in France, Greece and Portugal (Geschwind, 1999).
Spanish GPs in ambulatory clinics were public employees paid by capitation.
Having given 2.5 hours per day consultation at the health centre, they were
free to undertake private practice thereafter. Public consultations were overburdened, giving GPs little chance to deliver high quality care. Consequently
most citizens had private insurance or visited their own public doctor as private
patients. They gained longer consultations while retaining the privileges of public coverage: diagnosis tests, referrals to specialists, prescriptions free of charge
or with a co-payment. These arrangements also enabled private insurance companies to offer lower premiums. Teachers and civil servants could, and still can,
subscribe to “Muface”, a public insurance company. They avoid public ambulatory clinics, use private practice, choose their GP and have free access to
specialist care. Muface pays doctors on a fee-for-service basis. In general,
though, private practice was more a complement to than a substitute for the
public sector in Spain.
Besides generalist doctors, Bismarckian and Semashko systems included
specialized doctors working in primary care – most often obstetricians and
paediatricians.
In some countries, partnerships developed, with a legal personality distinct
from that of private citizens or firms. Most British GPs were in partnerships by
1990 (in Germany fewer: around 25%). Typically these partnerships would have
five members or fewer. In England, each partner typically owned an equal share
of the capital of the partnership, which they would purchase on entering the
partnership and sell on leaving it. Selling lists of patients was made illegal in
1947, but for many years afterwards the cost of entering a partnership would
usually include an inflated price for equipment and furniture, ostensibly to
purchase the “goodwill”. The partners would jointly employ support staff
(nurses, receptionists, etc.). Partners usually kept their own personal lists of NHS
patients, although they could – and often did – combine their lists. Usually
the partners shared at least some of their private practice earnings, sometimes
all of them.
Both Beveridge and Semashko systems provided broader service PHC through
conventional, hierarchical organizations employing salaried staff. They varied
according to what services and professions they included, for instance whether
they covered social work (Northern Ireland, Poland), veterinary services (Italy),
kindergartens (East Germany), spas (USSR, East Germany), or medicine (provided by independent practitioners instead in some countries). Another variation was whether they were accountable to local government (Italy), the health
ministry (Portugal), both of these (USSR), or higher-level health organizations
(the United Kingdom). That determined how far operational decisions (about
budgets, staffing, repairs, working practices, etc.) were delegated to local managers (e.g. English community health services) or centrally prescribed (USSR);
(Burenkova, 1986).
In both Bismarckian and Beveridge systems private provision played a greater
role in PHC than in the hospital sector. When not provided by the public sector,
nursing and domestic help in the patient’s home was provided either by private
individuals or, in the case of nursing, employment agencies (private firms).
Firms (as opposed to individual professionals and partnerships) rarely provided
The evolving public-private mix
133
medical care, but did usually supply pharmaceuticals, equipment and other
consumables on a commercial basis (another contrast with the Semashko
system).
Main reform trends during the 1990s
The dramatic change after 1990 was the decline of the Semashko system. Reacting against Soviet policy, most CEE governments decided to replace it with
“western” practices. In that climate, the larger change of introducing a Bismarckian system or privatization were often more politically acceptable than the
smaller move to a Beveridge system. Western governments were also exporting
their own health policy models, for instance through the EU PHARE and TACIS
programmes. Other international organizations, especially the World Bank, the
WTO and the IMF, promoted “Washington consensus” policies of globalizing
CEE economies, privatizing wherever possible and dramatically reducing public
spending. Their policies helped to generate substantial reductions of public
spending on first-line medical care. In Russia, for instance, most polyclinics had
difficulty paying even the low official salaries, and could not purchase equipment or consumables. These conditions made western ideas for extracting more
health services from given resources doubly attractive to CEE health systems.
The Bismarckian model also appeared to offer a way of supplementing state
financing with private financing for health care. Not surprisingly, many CEE
countries changed primary care financing from public budgets to some form of
national health insurance.
During this period, primary care providers saw opportunities to consolidate
their incomes and renegotiate their relationship to the state. Virtually all the
CEE countries have permitted independent general practice (see Vignette 7.3);
however, the proportion of doctors working independently varies between
countries. Some countries (e.g. the former East Germany) have made it virtually
impossible for a physician not to be a private entrepreneur. In the former
Yugoslavia, general practice was already a recognized discipline. Bosnia
and Herzegovina, Croatia, and Slovenia relabelled it “family medicine” and
improved existing vocational training. Other countries re-introduced general
practice as an academic discipline, largely with support from abroad (e.g. Canada, the United Kingdom). Some projects (e.g. in Estonia) were successful, but in
other countries (e.g. “the former Yugoslav Republic of Macedonia”, Serbia) few
changes have taken place. Generally, the policy choice is between either accepting a longer transition period or the coexistence of salaried and independent
practice (Lember, 1998; Markota et al., 1999).
Western European countries’ economic problems, while nowhere near as
severe as in the CEE, still led to health system reform. Britain faced this predicament in the 1970s and by the 1990s Germany, Sweden and Switzerland
were also affected (Theurl, 1999; Bergmark, 2000). Initially many western
European health systems adopted a “strategy of managerialism” (Flynn, 1992),
trying to meet growing demands by exploiting resources more efficiently
instead of increasing them or radically restructuring their health systems. The
“New Public Management” provided a repertoire of methods: in primary
134 Primary care in the driver’s seat?
care, its main manifestations were cash-limited budgets (e.g sickness funds
negotiating global cash limits with providers), the substitution of cheaper
inputs (e.g. by redefining the division of labour between occupational groups
and promoting team-based PHC provision), and the introduction of performance indicators and evidence-based medicine. Vignette 7.1 illustrates this with
the example of Spain:
Vignette 7.1 Primary health provision in Spain
In the mid-1980s Spain reformed its public health services. The country
was divided into subareas of 5,000 to 25,000 inhabitants. Every citizen was
assigned a personal doctor and nurse, and received care from a subarea
team working in a health centre (in cities) or a local surgery (in rural
areas). Teams were composed of GPs, paediatricians, nurses, social workers
and a dentist working 36 hours a week for the public sector, acting as gatekeepers and providing preventive, curative and rehabilitative care. Nurses
receive a salary while doctors were paid by capitation or salary basis
depending on the region. Although doctors may undertake private practice outside working hours, the improved salaries, rising quality of services
and prestige of public GPs may explain why private insurance coverage
decreased from 20.2% in 1980 to 8.7% in 1990. Compared with the traditional system, the reformed system had fewer GP referrals to specialists,
hospital outpatient and inpatient departments and emergency rooms by
GPs. Physicians wrote 23% fewer prescriptions for pensioners and 17%
fewer for younger patients. Demographic, health or social variables did
not explain these differences. Reformed teams complied better with
protocols and guidelines for preventive care and follow-up of chronic
conditions such as diabetes and hypertension. A comparison of mortality
rates for 1984–1996 in three equally socioeconomically impoverished
zones of Barcelona showed a clear association between reformed PHC
services and a decrease in mortality due to stroke and hypertension. Satisfaction was significantly greater among people using the reformed PHC
centres (Gené-Badia et al., 1996; Villabi et al., 1999).
Comparable team-based innovations were promoted in Finland,
the Netherlands, Portugal, Sweden, the United Kingdom, and former
Yugoslavia in the 1980s.
During the 1990s, two main strategies in response to the economic pressures
were to promote competition and substitute private for public provision in
primary care. Drawing upon arguments developed by the New Institutional
Economics (Niskanen, 1973; Williamson, 1975), and, for health care, Enthoven
(1986), proponents of competition also suggested that one alternative to privatization could be reforming public services into public markets. In theory, the
resulting “quasi-markets” or “internal markets” could also be opened to private
The evolving public-private mix 135
finance and providers. Thus common economic pressures, moderate in western
Europe but extreme in CEE, produced rather convergent policies for primary
care provision across the continent.
Promoting competition and contestability
In Beveridge and Semashko systems, promoting competition among primary
care providers required separating existing organizations into financing and
planning levels in contrast with provider levels, and then creating competing
providers on the provider side (these distinctions already existed in Bismarckian
systems). One purpose of competition was to pay (or penalize) primary care
providers in ways that favoured those who contained costs or increased the
volume of care for a given budget. One method was to encourage patients themselves to choose between providers, who would then be rewarded for attracting
patients (Saltman and Von Otter, 1992). Additionally, the purchasing body
could establish benchmarking, i.e. publish ranked “performance” indicators or
“league tables” geared to best practice. In England and Wales, for example,
experiments are under way to publish comparative data about GPs’ clinical
services. Even while fundholding was in operation, however, English GPs
proved more inclined to work collaboratively than to compete.
Work as well as payments could be transferred between providers. In
Beveridge systems, many health ministries promoted competition by reforming
their primary care providers into “public firms”. These “public firms” have in
some cases used their autonomy to adopt service models used in the private
sector so as to compete directly with private providers, thus reversing the
dynamic of privatization. Conversely, in some countries (e.g. Spain, the United
Kingdom), hospital accident departments compensate for deficiencies in primary care services (Rodriguez et al., 2000). The public firm model enables hospitals to turn this into an opportunity to compete for income. In Germany it is
proposed to allow university polyclinics to see patients and be paid by sickness
funds for doing so – a move which GPs have complained is subsidized public
competition, weakening the local medical unions’ monopoly (Ärztliche Praxis,
9 May 2002; Die Welt, 5 October 2001). At least one patient organization has
welcomed the proposal for the same reason. The British NHS swiftly copied the
idea of convenience clinics (see below) opening 20 experimental free, publicfunded convenience clinics of its own, mainly in town centres but at least one in
a major airport.
To signal their unwillingness to let new providers enter primary care unless
existing providers become more efficient, governments have also begun supporting experimental new organizational forms and models of care such as
those illustrated in Vignettes 7.2 and 7.4. English GPs became more receptive to
new methods of clinical governance when they began to suspect that otherwise
the government would review the entire concept of medical self-regulation in
primary care.
136 Primary care in the driver’s seat?
Vignette 7.2
Personal Medical Service Schemes in England
Nearly all British GPs are self-employed and obtain most of their income
by contracting their services to the National Health Service. Since the NHS
began (1948), GPs have provided most primary care services. Since 1997,
around 20% of the GPs have exercised a new option to drop the national
contract and instead work as part of a Personal Medical Services (PMS)
scheme under contract to their local Health Authority or PCT. However,
the 1997 legislation also allows non-medical providers to make such contracts. For GPs who do not opt for PMS status, the national contract has
been radically renegotiated. It divides GPs’ tasks into three categories. All
practices have to provide the “essential” services. GPs can opt out of providing “additional” and “enhanced” services, but if they do so their
payments are reduced. Then the local Primary Care Trust has either to
provide these services itself or subcontract another organization to do so.
These proposals thus present an opportunity for new providers, both public and private, to work alongside GPs in delivering such services as
chronic disease management, preventative care, home visits and out-ofhours care. Besides facing new competitors, GPs’ position as the preferred
providers of primary care is being eroded.
All forms of provider competition require meso-level bodies to use contracts,
incentives and payment systems that make primary care providers compete
over the range and quality of services. Besides new GP contracts in England
(Vignette 7.2), Italy and Norway, there have been HMO-like experiments in
Germany and Switzerland.
The new forms of contract are also used to apply cash limits (e.g. in
Belgium, England, France, the Netherlands; and planned in Germany). In
Beveridge systems, governments directly control the purchasing organizations and their budgets. In Bismarckian systems, these ends were achieved
by promoting competition among the purchasers to ensure that providers
contain costs and introduce new forms of care, and ensure that patients
would choose their sickness fund (or other insurer) on the grounds of
provider quality and range of services. Such were the Dekker and Simons
reforms in the Netherlands, and similar reforms in Austria, Belgium,
Germany and Switzerland. Foreseeing the danger of adverse risk selection
(insurers “cream-skimming” the most profitable or least costly patients to
treat), governments tried to make case-mix differences cost-neutral to
sickness funds and PHC providers. In Germany and Switzerland, complex
risk structure equalization methods (Risikostrukturausgleich) were therefore
introduced.
The evolving public-private mix
137
Substituting private for public provision
Privatization across western European primary care has been implemented in
two main ways:
(1) Substitution of private for public finance has occurred in some western countries, particularly in the form of increasing co-payments for primary care
services. Italy has gradually been extending co-payments for primary care
services since the 1980s. In some Bismarckian systems (e.g. France) patients
typically buy supplementary private health insurance to cover procedures
that do not have full social security cover (Geschwind, 1999). In most of
the former USSR Territorial Funds for Compulsory Medical Insurance were
created in the 1990s, financed by mandatory contributions from workers
and firms. Municipalities pay the subscriptions of non-economically active
people.
(2) Privatizing primary care providers has occurred in some countries as part of
official policy. Traditionally, of course, Beveridge and Bismarckian systems
allowed primary care providers to undertake private and publicly funded
work in parallel. In the 1990s, CEE countries accomplished privatization
partly by legalizing existing illicit private practice. For example, following
new legislation, dentists in the former Yugoslavia were among the first
health professionals in that country to embrace independent practice. They
declared their existing “secret” practices and have generally continued to
work for out-of-pocket payment for the same clientele (Švab et al., 2001). In
Spain the market share of private medicine is higher in primary than in
hospital specialist care (Urbanos-Garrida, 2001). The German medical networks described below (Vignette 7.6) can collectively pursue private practice.
These two strategies were not always consistent with each other or other
policies. For example, evidence-based medicine, the substitution of nonmedical for medical staff and the increasing need to coordinate primary health
care services all suggest a larger provider unit than the individual doctor. Yet
privatization policies worked in exactly the opposite direction when, as in many
CEE countries, they involved abolishing polyclinics.
Outstanding innovative experiences
Both competition and privatization have resulted in diversification of primary
care providers. However, the resulting fragmentation and competition in the
primary care sector did not remove governments’ desire to influence the quality
of these services and to promote better coordination between general practices,
or the local equivalent, and other primary and social care providers. Various
primary health care providers themselves often need to collaborate for practical,
therapeutic purposes. In the absence of bureaucratic powers of coordination,
many governments promoted networks of PHC organizations to compensate
for the organizational fragmentation of PHC and to strengthen PHC providers’
accountability to government, investors and the public. The following vignettes
illustrate this.
138 Primary care in the driver’s seat?
New forms of private primary care provision
Apart from independent medical practice, which was an innovation for the CEE
countries but not for western Europe, four main new types of primary care
provider appeared. Commercial providers exist, but are exceptional. In Britain,
one of the few examples of successful commercial providers have been walk-in
clinics recently opened in major London railway stations. Patients have consultations without prior appointment on a first-come-first-served basis. Similar
private walk-in clinics were started in Swedish cities as early as 1983 (Saltman
and von Otter, 1987). Other new forms of private and/or mixed public-private
service delivery are: medical cooperatives (see Vignettes 7.3 and 7.4) and
collaborations between doctors, other health professions and voluntary organizations (Vignette 7.5).
PHC networks
During the 1990s, the need to coordinate medical care with nursing, paramedical and social care became greater as chronic disease, care of the elderly and
substitution for hospital care became more prominent. Where the coordination
of PHC services by public bodies has been dismantled or never existed, these
trends have made it necessary nevertheless to construct alternative mechanisms
to coordinate the public-private mix at local level. Three categories of network
Vignette 7.3
Medical cooperatives in former Yugoslavia
Health centres remain the predominant form of PHC organization but
GPs can opt to work as independent solo GPs who refer their patients to
specialists. The problem of waiting lists for some specialists is generally
solved by making direct out-of-pocket payments to those specialists.
However, medical cooperatives as a form of joint venture between primary
and secondary specialists do exist in both Croatia and Slovenia, although
they are relatively rare. Examples exist of firms owned by GPs and employing secondary care specialists, mostly on a part-time basis or even through
a part-time contract. Most frequently, the aim of such a cooperative is
to make specialist services more readily available to patients registered
with the cooperative. Additional employment of salaried specialists in
independent practices has been recognized as a source of concern by
policy-makers and hospital managers, but the problem has not been
adequately solved. Quite often the cooperatives are a cover for a specialist
secondary care, which is one of the most frequent forms of independent
and private practice. In some cases established specialists ask to be
licensed as GPs only to be able to have patients registered with them and
to offer their specialist services to their patients under the title of general
practice, which is paid for largely by the state.
The evolving public-private mix
Vignette 7.4
139
Medical cooperatives for out-of-hours services in England
After 1990 English GPs increasingly organized out-of-hours clinics on a
cooperative basis. GPs have been formally responsible for providing allday every-day medical cover for their patients. Previously this requirement was most often met by hiring commercial deputizing services, and
in many places it still is. Cooperatives consist of a group of GPs (membership is voluntary) who take it in turns to provide night-time and weekend
services for patients of all the GPs in the cooperative. The cooperative pays
a fee for this work. All members also contribute money to meet these and
other running costs, but these contributions are in turn reimbursed from
public budgets. (Thus, an individual GP can either gain or lose money on
balance, depending on the sums involved and how much out-of-hours
work he or she does.) A few of these cooperatives have gone further, by
providing clinic premises which patients can attend and in some places
they have taken responsibility for the NHS Direct services described below.
Out-of-hours services provided by patients’ own GPs appear to be of
somewhat higher quality than the commercial alternatives (Cragg et al.,
1997), although little evidence yet exists comparing them with hospital
emergency departments.
Vignette 7.5
The Entitat de Base Asociativa, Catalonia
The Health Care Organization Law (Llei d’Ordenació Sanitària de Catalunya,
1990) broke the monopoly of primary care provision by regional public
authorities staffed by civil servants. Most hospitals were already owned by
organizations belonging to churches, municipalities, regional government or private owners and managed in a similar way to private organizations with more rapid and flexible personnel and financial management
processes than in the public sector. Many of these organizations launched
primary care services (Martí and Grenzner, 1999; Violan et al., 2000). In
the mid-1990s five EBAs (Entitat de Base Asociativa) appeared. The EBA is a
private for-profit enterprise run by a team of doctors and nurses who care
for a defined population. It receives a capitation-based budget for doctors’
and nurses’ salaries, premises, diagnostic tests, referrals to specialists and
prescriptions. A study in Barcelona identified no statistically significant
differences in the use of medical services, indicators of clinical practice, or
quality and pharmacy costs between three different primary care management schemes; although the per capita ratio of nurses was lower in the
non-public organizations (Guarga et al., 2000). Breaking the public
services’ monopoly of primary care was seen as powerful stimulus to promoting quality not only in privately managed organizations but also in
the publicly managed regional ones.
140 Primary care in the driver’s seat?
have emerged. A “virtual primary care organization” is organized around a care
pathway, specific care group or geographically defined population, such as (in
the Netherlands) local collaborations of health, local government and voluntary services for the purpose of coordinating primary medical care with paramedical services, nursing home services and social services (Houtepen and
Ter Meulen, 2000). German Integrated Care Structures (see Vignette 7.6) and
English Primary Care Trusts (Vignette 7.7) are further instances. A second type,
found in England, Germany (see Vignette 7.8) and Poland, are professional networks for education, clinical audit and promoting evidence-based medicine
(EBM). The third category are policy networks that coordinate independent
general practices and other PHC providers in implementing intersectoral “new
public health” initiatives (e.g. the WHO Healthy Cities Programme, Health
Action Zones in England).
Impact of reforms and innovations
More evidence is available about the organizational impacts of European health
care reforms on the range and coordination of providers than about their health
impacts or effects on patient satisfaction. Better evidence is available about
separate local initiatives than about the effects of privatization and competition
policies as a whole.
The evidence is equivocal about the effects of competition as a means of
selecting primary care providers and coordination of the private-public mix. A
Vignette 7.6
Integrated care structures in Germany
Several countries have attempted to construct Health Maintenance
Organizations (HMOs), tending to favour the Preferred Provider Organization (PPO) and Independent Practice Association (IPA) models (Robinson
and Steiner, 1997). In the German and Swiss cases, specific financial
arrangements are made with a medical network such as those described
above, creating an “integrated care structure” (integrierten Versorgungsstruktur). Selected doctors become preferred providers and negotiate special
contractual terms with local sickness funds, side-stepping the usual
German arrangements under which the local doctors’ union apportions a
fixed budget between doctors according to their activity. In some places
the sickness fund negotiates a block payment, either for all services,
for services to a specific care group, or for new PHC services, such as
emergency services and nursing care (Südbaden) and walk-in clinics
(Schleswig-Holstein). Other services remain financed under the old system. The largest German network is the Berlin Doctors’ Networks (Praxisnetze Berliner Ärzte) which involves industry-based sickness funds. It
proved easy to recruit doctors to the scheme but to attract patients it had
to offer discounts and recruit further sickness funds (Plassman, 1998).
The evolving public-private mix
Vignette 7.7
141
English Primary Care Trusts
All English GPs must now be members of a local Primary Care Trust.
The chair and a majority of seats on the PCT’s Professional Executive
Committee are elected by GPs, who are independent practitioners. PCTs
are becoming responsible for managing PHC (including community
health services) for the clinical quality of primary medical care and for
commissioning secondary care. However, most GPs are not contracted to
PCTs but hold a contract with the Department of Health, such that the
PCT has no direct contractual control over them. A minority now work
under contract to the PCT (see above) but these contracts are not a strong
instrument of control (Sheaff and Lloyd-Kendall, 2000; Sibbald et al.,
2001). PCTs may also employ GPs, but very few do so as yet. Consequently
the PCT has to influence GPs mainly by using information, knowledge,
education, local professional and friendship networks, by making “gentleman’s agreements” and by subtle political pressures (Sheaff et al., 2004).
PCTs are starting to collect data on the current state of clinical practice and
attempting to implement evidence-based guidelines produced by the
National Institute for Clinical Excellence (NICE) and other national
bodies.
Vignette 7.8 Practice networks in Germany
Practice networks in Germany illustrate the professional network model.
Following the 1997 German health system reforms, some independent
doctors formed networks, some of which included other professions.
Physicians join voluntarily. Some regard the networks’ independence
as increasing GPs’ bargaining power with sick funds (Plassman, 1998).
About 160 networks have been created, though some have subsequently
dissolved, with sizes ranging from 13 to 1800 doctors (the Berlin Kodex
project). Their functions range from communications and advice giving
only (e.g. in Bielefeld) to clinical quality management, usually through
quality circles (sometimes interdisciplinary) or clinical audit. They also
enable doctors to purchase consumables more cheaply (Szecseny et al.,
1999) and to share equipment. Some have created combined budgets
for medical and non-medical expenses (paramedical services, pharmaceuticals). The network in Münster has also created patient registers
for chronic diseases and provides out-of-hours services. Another common
activity is to establish cross-referral systems between generalist and
specialist doctors within PHC, and to ensure that hospitals provide ambulatory services such as day surgery which are still relatively new in
Germany.
142 Primary care in the driver’s seat?
number of new forms of primary care provider have appeared. The reforms have
also stimulated quality management activity, partly through publicly comparing primary care providers, a corollary of competition. Evidence about what
effects these quality management activities actually have upon health outcomes
is voluminous, complex and equivocal (Grimshaw et al., 2001), but when
a number of different activities occur concurrently, they do appear to promote
the practice of EBM and to that extent improve clinical outcomes. Evidence
about patient satisfaction is equally indirect. When they are adequately
resourced and given sufficient managerial autonomy, public providers in Beveridge systems can improve primary care access and quality, and out-compete
private providers. Recent changes in primary health care may also have contributed to a Europe-wide decline in lengths of hospital stay (see Chapter Two). PHC
contributes through providing domiciliary care, ambulatory clinics (Germany),
“near-patient” diagnostic services (Britain) and “hospital at home” services
(France). Although pro-competition policies helped open up PHC to the new
kinds of services that were required, these changes largely reflect the new collaborative networks of the kinds outlined above.
Various problems have also arisen. When regulations on sickness funds have
been relaxed, for example, a side effect seems to have been to stimulate them to
act more acquisitively. Regulatory changes subtly changed the “private” character of some sickness funds from a not-for-profit charity-oriented character to
one much (but not completely) like a conventional financial institution. In the
Netherlands, sickness funds reacted to competition as much by merging
(reducing competition) as by managing providers more assertively. Scope for
competition among primary care providers proved to be limited. Unlike inpatient care, primary care has to be provided near the patient’s home, and primary
care patients tend to value a long-term relationship with their doctor and do not
change provider readily (Sheaff, 2001). Provider competition presupposes excess
capacity, which exists in CEE and, say, Germany but not everywhere (e.g. there
are shortages of GPs in Britain and the Russian Federation). There is evidence
that English and German GPs prefer cooperating to competing with each other,
and professional networks generally tend to inhibit competition.
As for privatization, reforms in some countries (e.g. Malta, Romania, Russia)
have redefined publicly funded primary health care more narrowly. Less medicalized, more socially oriented services such as care of the elderly or disabled,
and environmental and occupational health have passed to other ministries
whose role is more to oversee private markets than to provide or finance
services. Fragmentation has occurred at a time when, as noted, demographic
changes, shifts from acute to chronic disease and the substitution of primary
for secondary care necessitate closer coordination. In these circumstances,
PHC systems have relied on the purchasers to coordinate services and have
constructed networks.
When private commercial insurers have made inroads in Bismarckian systems, adverse risk selection has reappeared. Evidence since 1990 repeats this
dating back to the 1940s and earlier. Thus in Spain, private insurance appeared
to reduce “excess” (i.e. higher than average) consumption of PHC and the
insured were disproportionately in one region (Catalonia), the cities and richest
classes (Rodriguez et al., 2000). Despite having to offer all adult patients the
The evolving public-private mix
143
same premiums, some deregulated Swiss sickness funds achieved profit rates
twice as high as others in 1998 by attracting clients with “better” risk profiles
(Theurl, 1999). In CEE, the pattern is sharper. Many Russian firms are unable or
unwilling to pay sickfund premiums. Whether municipalities can do so depends
on their own local tax base, which is small in most Oblasts. Privatization and
competition among sickness funds thus appears to have mainly adverse effects
on patients in terms of exposing them to great risk selection and thus reducing
access to primary care services.
On the provider side, “private” primary care has become an increasingly
diverse category. Indeed, assimilating all the new kinds of providers as ‘private’
obscures important differences. They pursue different goals, respond to different incentives and bring different resources. It might appear that a greater variety of providers increases the risk of adverse selection, or at least differential
access to health care. However, in Britain it appears that although GP fundholders succeeded in gaining easier access to hospital and community services for
some of their patients (Glennerster and Matsanganis, 1992), there was no reduction in access for non-fundholders’ patients (Dowling, 2001). Diversification of
providers makes primary care provision more contestable, with the benefits
noted above.
Against this, private provision of primary care has in some ways obstructed
reform. Independent GPs can choose whether to scrutinize their clinical practice critically or, as the uneven development of practice networks in Germany
indicates, not to. Even English GPs, who are obliged to participate in “clinical
governance”, vary considerably in how actively they do so (Sheaff et al., 2004).
Similarly, complications with private pension rights discouraged many English
GPs from joining PMS schemes, as did partnership arrangements; a partnership
develops at the pace of its most conservative member. Evidence from several
countries (Italy, Portugal, Spain) indicates the difficulty in achieving patient
satisfaction under Beveridge systems, and in quasi-market systems derived from
them, when publicly-employed doctors are free to both practice privately and to
manage their own public sector workload. In Greece, the result is under-thetable payments to GPs (Daniildou, 2002). These experiences suggest that in
Beveridge systems the underregulated coexistence of public and private practice
creates dual standards of access even when the state funds universally free
health care.
Reform experience shows that doctors and patients respond to financial
incentives (e.g. for patients to accept gatekeeping or a restricted choice of doctor). GPs also respond to the possibility of alternative providers entering primary care. However, these are not the only incentives. The experience of quality
management and medical networks suggests that non-financial incentives, such
as opportunities to pursue specific clinical interests and making clinical practice
transparent to outsiders, can also be effective.
Discussion and policy lessons
Together, the above impacts suggest three sets of policies which counteract each
other and wider policy aims (Rhodes, 1997):
144
Primary care in the driver’s seat?
• Privatization of primary care purchasing can stimulate adverse selection and
thus compromises universal access to PHC.
• Competition and privatization can compromise the policy-responsiveness of
•
primary care organizations.
By dispersing services among different providers, competition and privatization can compromise the growing requirement for closer coordination of PHC
services.
More positively, benchmarking, contestability and competition, as well as giving
public providers the latitude and resources to adapt ideas developed elsewhere
and to implement their own ideas for innovation, have stimulated existing
public providers to offer forms of service that appeal more to patients. There
have been the benefits of a spread of evidence-based medicine and the opening
of primary care to new providers, organizational innovations and models of
care. Hence the value from competition has come less from stimulating microlevel competition between local GPs than from opening up to new providers,
new models of care and new forms of organization; in effect, generating a new
public-private mix.
What policy implications follow? One is the gradual erosion of the medical
monopoly in primary care: a politically delicate issue that may yet trigger resistance to further changes. A second is that competition and patient choice,
should not simply be equated with privatization and conventional, commercial
markets; or vice-versa. Paradoxically, competition occurs among public primary
care providers as well as actors such as sickness funds which are neither
fully commercial nor public bodies, while some forms of private primary care
provider (e.g. English general practices) display little competition. Although
economist orthodoxy asserts that private providers are more efficient than public ones, no evidence of that emerges from the European experience. The corresponding policy implication would be to promote innovation, experimentation
and the contestability of provision rather than competition and privatization
for their own sake.
Increased diversity of “private” providers raises the question of whether
some kinds of privatization are better than others. Many innovations have
emerged from the voluntary sector and independent practitioners. The entry of
new providers needs to be regulated so as to ensure patient safety and redress,
but without creating new monopolies of provision. In Beveridge systems especially, it will be necessary to regulate how providers combine public with
private practice so as to safeguard the interests of publicly funded patients.
Ensuring policy responsiveness and accountability necessitates making clinical
practice more transparent and ensuring that the public bodies responsible for
primary care actually obtain the necessary information (and use it). Regulations
and contracts will thus need to become more rigid in these matters, but
more flexible in others. They also need to be supplemented by more positive
methods of coordinating services, for instance by developing primary health
care networks.
The evolving public-private mix
145
References
Bergmark, A. (2000). Solidarity in Swedish welfare – Standing the test of time? Health Care
Analysis 8: 395–411.
Burenkova, S.P. (ed.) (1986). Sbornik Shtatnykh normativov uchrezhdeniya zdravookhraneniye.
Moscow: Meditsina.
Cragg, D.K., McKinley, R.K., Roland, M.O. et al. (1997). Comparison of out of hours care
provided by patients’ own general practitioners and commercial deputising services:
A randomised control trial, British Medical Journal 314 (18 January): 186–88, 190–193.
Daniildou, S. (2002). Roemer’s Law: Does it Apply in Greece? Paper presented at the Strategic
Issues in Healthcare Management conference, University of St. Andrews, 11 April.
Dowling, B. (2001). GPs and Fundholding in the NHS. Aldershot: Ashgate.
Enthoven, A. (1986). Managed competition in health care and the unfinished agenda,
Health Care Financing Review, supplement: 105–117.
Flynn, R. (1992). Structures of Control in Health Management. London: Routledge.
Gené-Badia, J., Goicoechea, J., Sadana, R., et al. (1996). Primary health care in Southern
European countries: an analysis of cross-national experiences, in Goicoechea, J. (ed.)
Primary Health Care Reforms. World Health Organization Regional Office for Europe.
Primary health care reforms, Fifth Forum on Primary Health Care Development in
Southern Europe and its Relevance to Countries of Central and Eastern Europe. The
Way Forward (Andorra la Vella 3–6 February 1993). Copenhagen: WHO Europe.
Geschwind, H.J. (1999). Health care in France: recent developments, Health Care Analysis
7(4): 355–362.
Glennerster, H. and Matsanganis, M. (1992). A Foothold for Fundholding. London: King’s
Fund.
Grimshaw, J.M., Shirran, L., Thomas, R., et al. (2001). Changing provider behavior. An overview of systematic reviews of interventions, Medical Care 39(8), supplement 2: 2–45.
Guarga, A., Gil, M., Pasarín, M., Manzanera, R., Armengol, R. and Sintes, J. (2000).
Comparación de equipos de atención primaria de Barcelona según formulas de gestión [Comparison of primary care group management formulas in Barcelona],
Atención primaria 26: 600–606.
Houtepen, R. and Ter Meulen, R.T. (2000). New types of solidarity in the European welfare
state, Health Care Analysis 8(4): 329–40.
Lember, M. (1998). Implementing modern general practice in Estonia, Acta Universitatis
Tamperensis 603: 1–74 (Tampere: University of Tampere).
Markota, M., Švab, I., Saražin-Klemenčič, K. and Albreht, T. (1999). Slovenian experience
of health care reform, Croatian Medical Journal 40(2): 190–194.
Martí, L.J. and Grenzner, V. (1999). Modelos de atención primaria en Cataluña [Primary
care models in Catalonia], Cuadernos de Gestión para el Profesional de Atención Primaria
5: 116–123.
Niskanen, W.A. (1973). Bureaucracy: Servant or Master? London: IEA.
Plassman, W. (1998). Vernetzte Praxen: Welche Modelle machen Sinn? [Which models
make sense?] Herz 23: 64–7.
Rhodes, R.A.W. (1997). Understanding Governance. Buckingham: Open University Press.
Robinson, R. and Steiner, A. (1997). Managed Health Care. Buckingham: Open University
Press.
Rodriguez, M., Scheffler, R.M. and Agnew, J.D. (2000). Update on Spain’s health care
system: is it time for managed competition? Health Policy 51: 109–131.
Saltman, R.B. and Von Otter, C. (1987). Re-vitalizing public health care systems: A
proposal for public competition in Sweden, Health Policy 7: 21–40.
Saltman, R. and Von Otter, C. (1992). Planned Markets and Public Competition. Buckingham:
Open University Press.
146 Primary care in the driver’s seat?
Sheaff, R. (1998). What is “primary” about primary healthcare? Health Care Analysis 6(4):
330–340.
Sheaff, R. (2001). Responsive Healthcare. Buckingham: Open University Press.
Sheaff, R. and Lloyd-Kendall, A. (2000). Principal-agent relationships in general practice:
the first wave of English PMS contracts, Journal of Health Services Research and Policy
5(3): 156–163.
Sheaff, R., Sibbald, B., Campbell, S. et al. (2004). Soft governance and attitudes to clinical
quality in English general practice, Journal of Health Services Research and Policy 9(3):
132–138.
Sibbald, B., Petchey, R., Gosden, T., Leese, B. and Williams, J. (2001). Salaried GPs in
PMS Pilots: Impact on Recruitment, Retention, Working Practices and Quality of Care.
Manchester University: NPCRDC (National Primary Care Research and Development
Unit).
Švab, I., Markota, M. and Albreht, T. (2000). The reform of the Slovenian health care
system: from capitalism to socialism and back, Zdrav Vestn 69: 791–798.
Švab, I., Vatovec-Progar, I. and Vegnuti, M. (2001). Private practice in Slovenia after the
health care reform, European Journal of Public Health 6(4): 407–12.
Szecseny, J., Magdeburg, K., Kluthe, B. et al. (1999). Ein Praxisnetz erpolgreich gestalten –
Erfahrungen und Ergebrisse aus zwei Jahren “Ärztliche Qualitatsgerieinschaft Ried” [To
build a medical practice network successfully – two years operating experience and results of
the “Ärzliche Qualitatsgereinschaft Ried”]. Göttingen: AQUA – Institut fur argewandte
Qualitätsforderung und Forschung im Gezundheitswesen (AQUA-Materialen Band
VII) (www.aqua-institute.de/projekte_reid.html, accessed 18 August 2005).
Theurl, E. (1999). Some aspects of the reform of health care systems in Austria, Germany
and Switzerland, Health Care Analysis 7: 331–54.
Urbanos-Garrida, R.M. (2001). Explaining inequality in the use of public health care
services: Evidence from Spain, Health Care Management Science 4: 143–57.
Villalbi, J.R., Guarga, A., Pasarín, M.I. et al. (1999). Evaluación del impacto de la reforma de
atención primaria sobre la salud [Health impact evaluation of primary care reform],
Atención Primaria 24: 468–474.
Violan, C., Elias, A. and Ponsà, J.A. (2000). El modelo catalán de atención primaria
[The Catalan primary care model], Cuadernos de Gestión para el Profesional de Atención
Primaria 6: 43–47.
Williamson, O.E. (1975). Markets and Hierarchies. New York: Free Press.
Zarkovic, G., Mielck, A., Jaohn, J. and Beckmann, M. (1994). Reform of the health care
systems of the former socialist countries: problems, options, scenarios, GSF-Bericht,
GSF (MEDIS) Institut für medizinische Informatik un Systemforschung 9: 1–163.
part
two
Changing institutional
arrangements 83
Changing working
arrangements 147
Changing quality standards 201
chapter
eight
Changing task profiles
Bonnie Sibbald, Miranda Laurant
and Anthony Scott
Introduction
Skill mix is a term used variously to refer to: the mix of skills or competencies
possessed by an individual; the ratio of senior to junior grade staff within a
single discipline; and the mix of different professions within a multiprofessional team. General practice shows considerable variations both within
and between countries in all three aspects.
General practitioner partnership size is growing in many European countries,
with consequent role differentiation among doctors. Nurses are increasingly
employed to undertake simple clinical tasks such as taking blood samples and
syringing ears. In some countries, notably the United Kingdom, nurses have
moved to more advanced roles in first contact care and the management of
patients with stable chronic conditions such as asthma, diabetes and cardiovascular disease. Primary care teams may be further extended through the
addition of medical specialists, therapists, or social care workers, as in Finland.
Other countries are moving in a similar direction. The United Kingdom, for
example, saw a marked rise throughout the 1990s in the prevalence of general
practices with a mental health counsellor and “outreach” clinics staffed by
hospital-based medical specialists. The Netherlands has introduced policies to
enhance collaboration among GPs, primary care psychologists and social workers (Buitink, 2000). The dominant trend is towards a more complex skill mix
reflected by larger and multiprofessional teams, and increased role differentiation within teams.
Factors governing change
The factors driving such changes in skill mix are many and complex but may be
distilled into the following broad groups:
150 Primary care in the driver’s seat?
• wider environment;
• policy;
• payment systems;
• professional regulation and training;
• professional attitudes.
The wider health care environment provides the impetus for change. Rising
demand for care, health workforce shortages, and the rising costs of health care
provision are powerful factors stimulating the revision of health professional
roles. Policy-makers respond by articulating the benefits to be achieved through
new ways of working. Payment systems and professional regulatory systems
determine whether policy will be implemented in practice. The pace of change
is moderated by the extent to which professionals need to be retrained and their
attitudes to negotiating new roles.
Wider environment
Population ageing has placed increasing pressure on health care systems
throughout the developed world, while, at the same time, medical advances
have increased patient expectations. Rising demand and cost of care has led
many governments to experiment with cost-cutting reforms. One strategy has
been to make GPs the “gatekeepers” to expensive hospital care. A second has
been to shift services, such as minor surgery and chronic disease management,
from hospitals to general practice. A third strategy has been to shift work from
high to low cost health professionals.
Shortages of particular professional groups may additionally accentuate the
need to find alternative care providers. In the Netherlands, the United Kingdom,
and elsewhere in the developed world, the effective size of the GP workforce has
fallen owing to a shift towards part-time working accentuated by the increasing
proportion of female doctors (Boerma, 2003). As nurses can be trained more
quickly and cheaply than doctors, expanding the nurse numbers and extending
their role into the medical arena is seen to be an effective strategy for dealing
with medical shortages. Similar arguments may be applied to the use of
unqualified health care assistants as substitutes for nurses when the latter group
is in short supply.
Policy
Multiprofessional teamwork is a widely favoured strategy for addressing the
problems created by rising demand and cost. Good teamwork is thought to
enhance the quality of care, constrain costs, and make best use of limited
human resources. Quality improvements are sought through the enhanced
coordination of care delivery and by the opportunity for specialization within
larger teams. Cost savings are sought through economies of scale and scope,
and by shifting care from expensive to cheaper health professionals. Better use
of scarce human resources is sought by breaking down disciplinary boundaries
Changing task profiles
151
which prevent professionals being deployed where their skills can best be
utilized. Countries such as Italy, the Netherlands and the United Kingdom
have been persuaded by such arguments to promote the development of larger
multiprofessional teams (Department of Health, 2000; Landau, 2001).
Payment systems
The successful implementation of policy requires payment systems which
reward providers for making the desired changes. Where there is no financial
advantage for providers, the pace of reform is likely to be negligible.
In the United Kingdom, successive reforms to payment systems for general
practice have favoured growth in the size and complexity of general practice
teams. The biggest impact was brought about by the 1990 GP contract which
gave doctors a budget (i.e. fundholding) with which to purchase the services of
community nurses and other health professionals. GPs encouraged primary care
nurses to undertake extended roles, largely in the areas of health promotion and
chronic disease management (Hirst et al., 1995). The larger practices were best
able to find the money and other resources needed to extend nursing roles, and
those practices which enhanced their skill mix in this way were best able to meet
the new performance targets attracting payment (Baker and Klein, 1991). Thus
economies of scale and scope have accelerated growth in team size and complexity. A similar situation prevails in other countries (Nijland et al., 1991;
Commonwealth Department of Health and Family Services, 1996).
A closely related issue is whether payers can be billed for the services delivered
by non-physicians within primary care teams. In the United States there is considerable variation in whether “mid-level” providers such as nurse practitioners
and physician assistants are able to charge for their services or whether the costs
must instead be subsumed as a physician overhead. Where mid-level practitioners are able to bill for their services, there is a higher prevalence of such
providers (Sekcenski et al., 1994). A randomized controlled trial examining the
effectiveness of substituting nurse practitioners for Ontario family doctors concluded that substitution was not cost effective for general practices because
payment systems in the 1970s did not enable doctors to bill fully for the services
provided by their nurses (Spitzer et al., 1974). In the Netherlands, a covenant
was introduced in 1999 to enable GPs to employ nurse practitioners (Ministerie
van Volksgezondheid, Welzijn en Sport et al., 1999); but numbers have grown
slowly owing to disagreements about the level of reimbursement (De Vries,
2001).
Professional regulation and training
Governments and professional governing bodies specify the scope of practice
for the majority of clinical professionals. These regulatory boundaries influence
team composition by limiting the opportunities for extending the role of particular health professionals. The ability to substitute doctors for other health
professions is constrained, for example, by the drug prescribing rights permitted
152 Primary care in the driver’s seat?
to non-physicians. The solution is to change the statutes governing scope of
practice. England, for example, has extended prescribing privileges to nurses
(Department of Health, 2002).
Staff taking on new or extended roles need to be trained for this work. The
speed with which skill mix changes can be realized therefore depends on the
range of pre-existing skills within a particular health profession and the amount
of additional training required to extend those skills. The bigger the gap
between existing and desired skills, the bigger the investment needed to achieve
change and the slower the pace of development. Central and eastern European
countries wishing to move from a hospital-centred to a general practice-centred
health care system have had to develop new systems for training doctors as
experts in family medicine – a process which takes many years to implement
(Gibbs et al., 1999). In contrast, the rapid introduction of nurse-led chronic
disease clinics in British general practice was facilitated by the high level of skills
already possessed by practice nurses and further supported by the provision of
short courses. Even so, the pace of service development in the 1990s often outstripped the ability of training programmes to equip nurses for these new roles
(Atkin et al., 1994).
Professional attitudes
A more pervasive factor affecting the pace of skill mix change is the attitude of
health professionals to renegotiating new boundaries between themselves and
other disciplines. In the United Kingdom, GPs initially welcomed extended roles
for practice nurses where these enabled doctors more easily to fulfil their contractual commitments. This, however, conflicted with nurses’ views that modifications to their role should be guided by concerns about developing nursing as
an autonomous profession which is complementary, not subservient, to medicine and medical professionals (Atkin and Lunt, 1996). As the overlap between
nurse and physician roles in primary care has grown, GPs have begun to voice
concerns that nurses may erode the doctor’s role (Wilson et al., 2002). In the
Netherlands GPs have been reluctant to introduce nurse practitioners, preferring
to use practice nurses who they have themselves trained. For their part, practice
nurses are anxious that nurse practitioners might usurp their role (Vogel, 1998).
Mechanisms of change
Skill mix changes may be grouped according to the type of organizational
process employed to bring about change.
Within general practice, skill mix change may be brought about through:
• enhancement – extending the role or skills of a professional group;
• substitution – exchanging one type of professional for another;
• delegation – shifting care provision from a senior/higher grade to a junior/
lower grade person within a profession;
• innovation – introducing a wholly new type of worker.
Changing task profiles
153
Skill mix may additionally be altered by changing the boundary between general
practice and other patient services. This may include:
• transfer – moving the provision of a service to general practice from another
health care sector, e.g. substituting general practice for hospital care;
• relocation – shifting the venue of a service to general practice from another
•
health care sector without changing the provider, e.g. running a hospital
clinic in a general practice setting;
liaison – using medical/clinical specialists to educate and support primary
care teams in their care of patients.
In practice skill mix change is often complex, involving interdependent
changes in a number of these facets. For example, asthma care may be shifted
from hospitals to general practice (transfer). In order to support this change, a
practice nurse may acquire specialist skills in asthma care (enhancement) enabling her both to extend the range of service provision and reduce the demand on
GPs (substitution). Routine tasks formerly undertaken by the nurse, such as
patient reception, may in turn be delegated to a more junior nurse (delegation)
or a non-clinical assistant (substitution). Hospital-based specialist nurses or
doctors may continue to advise and support the primary care team in its
management of patients (liaison).
Impact on care: role enhancement, substitution, delegation
and innovation
The overarching purpose of skill mix change is to improve health care effectiveness and efficiency. The question is whether it does so in practice. The evidence
base for change is generally not robust and has lagged behind service developments. Here we review the impact of role enhancement on health care effectiveness and efficiency, substitution, delegation, and innovation within general
practice teams.
Enhancement
Health promotion is one of the principal areas in which nurses working in
extended roles have increased the range of services available within primary
care. In the majority of British general practices, nurses are responsible for carrying out well-patient health checks and providing lifestyle and other interventions in accordance with agreed treatment guidelines (Atkin et al., 1994). Two
large-scale randomized control trials have shown that the benefits to patients of
such health promotion do not outweigh the costs (Family Heart Study Group,
1994; OXCHECK Study Group, 1995). The problem is not that nurses are unable
to deliver high quality care, but that the treatments they have been asked to
deliver are not sufficiently effective (Ebrahim and Davey Smith, 2002).
The situation is more promising in the area of chronic disease management.
Here, there is good evidence from controlled trials that the treatments to be
delivered by nurses are effective. Case studies show that the quality of care
154 Primary care in the driver’s seat?
delivered by nurses can be high (Charlton et al., 1991; Renders et al., 2001).
However, surveys of nurses working in extended roles suggest that, in reality,
many nurses are insufficiently well trained (Atkin et al., 1994). More importantly, there is a dearth of evidence about the overall cost-effectiveness of nurseled clinics (Scott et al., 1998).
GP roles may also undergo enhancement. Many GPs hold additional qualifications which enable them to provide more specialized services. In the United
Kingdom, this is becoming more formal, as GPs with appropriate qualifications
may apply to become “GPs with special interests” and so receive patient referrals
from doctors in neighbouring practices (Department of Health and Royal
College of General Practitioners, 2002). The intention is to expand specialist
care in the community and thus reduce waiting times and improve access for
patients. The key question which has yet to be answered is what activities will
GPs give up to specialize? Does the new balance between generalist and specialist skills result in a more efficient use of resources and increased benefits to
patients?
Substitution
The substitution of nurse practitioners for GPs is widespread in the United
States and becoming so in the United Kingdom. In these countries nurses are
able to undertake advanced training in diagnostics and therapeutics, which
enables them to manage a wide range of patient problems without reference to a
physician. Such nurses have increasingly been used to provide first contact care
for patients presenting in general practice settings. Systematic reviews of the
available evidence suggest that these nurses generally achieve as good health
care outcomes as doctors and may have superior interpersonal skills (Horrocks
et al., 2002).
The substitution of nurses for doctors might be expected to reduce costs.
However, research suggests this is not necessarily so. Compared with doctors,
nurses have longer consultation times, order more tests and investigations
and may recall patients at a higher rate, thus eliminating net savings in salary
costs (Venning et al., 2000; Horrocks et al., 2002). From the perspective of the
health care economy as a whole, it is generally cheaper to train nurses than it is
to train doctors, but savings are again eroded because nurses tend to have lower
lifetime workforce participation rates than doctors. The net saving to the state is
therefore difficult to predict and may differ between countries and over time.
Delegation
Delegation from senior to junior staff within a profession is not a strong feature
of general practice which has a “flat” organizational structure. Nevertheless,
when GPs come together to practice in groups there tends to be some degree of
differentiation among them in their clinical roles. Female doctors frequently
have lead responsibility for managing women’s health problems, if only because
female patients show a marked preference for female doctors (Chambers
Changing task profiles
155
and Campbell, 1996). The general assumption is that such role differentiation
within teams can enhance the quality of care provision to patients (Landau,
2001).
Innovation
New professional designations are introduced by clinical governing bodies
to acknowledge, and then regulate, health workers undertaking new roles
which require radical revisions to their training, skills and competencies.
The creation of “nurse practitioners”, “clinical nurse specialists” and “advanced
practice nurses” are good examples. As noted above, such skill mix change
centres on revising the work undertaken by existing types of health professionals, so it is arguable whether this should be regarded as “innovation” or
“enhancement”.
In the United States a unique professional – the physician assistant – has been
created. This position is used interchangeably with the nurse practitioner to
enhance health service capacity in many areas, notably family practice. Physician assistants are drawn from a wide variety of backgrounds which may
include nursing as well as other health or social care workers (Hooker and
Cawley, 2003). Research suggests there is little to distinguish nurse practitioners
from physician assistants in terms of the quality and scope of their care or costeffectiveness when used as physician substitutes (Mittman et al., 2002; Hooker
and Cawley, 2003). This makes physician assistants an attractive option for
expanding workforce capacity when there are shortages of medical and nursing
staff (Department of Health, 2000; Hutchinson et al., 2001).
Impact on care: service transfer, relocation, liaison
Skill mix may additionally be altered by changing the boundary between
general practice and other patient services. Here we review evidence of the
impact of service transfer, relocation and liaison on health care effectiveness
and efficiency.
Transfer
Rising demand and cost of care have led many policy-makers to transfer services
from hospitals to general practice in an effort to both enhance patient access
and constrain expenditure. Good research into the cost-effectiveness of such
service transfers is scarce (Scott, 1996; Godber et al., 1997). In particular, evaluations generally fail to take into consideration the wider implications of transferring resources from secondary to primary care. If GP referrals to hospitals
decline as a consequence of service transfer then the savings in hospital doctors’
time may be used for other purposes. This would only be cost-effective, however, if the benefits of these new activities outweighed the benefits of the service
transferred to general practice.
156
Primary care in the driver’s seat?
In the area of diabetes a systematic review of available research suggested that
the quality of care attained by general practice was equivalent to that provided
by hospitals, provided that general practice care was “structured”, i.e. patient
registers were established, patients were recalled for regular review, and reviews
were conducted according to clinical guidelines (Griffin and Kinmonth, 2000).
Other research has shown that patients attending general practice clinics report
improved access to care and reduced personal costs, largely through reduced
travel times. However, the direct costs of care provision may be higher in general
practice because practices consume more resources than hospitals in providing
the same standard of care (Diabetes Integrated Care Evaluation Team, 1994).
Minor surgery is another service where transfer from hospital to general practice is intended to enhance patient access and constrain cost. This was introduced in the 1990 GP contract in the United Kingdom in which doctors were
given financial incentives to undertake minor surgery. Experience showed that
the quality of care provided in general practice was initially poor due to
inadequacies in GP training, problems in maintaining surgical skills given low
patient volume, and inadequacies in the equipment and/or procedures used to
sterilize surgical implements (Finn and Crook, 1998). The only controlled study,
however, found no differences in health outcomes between hospital and
general practice, with patients treated by GPs reporting higher satisfaction and
shorter waiting times. The costs of general practice-based minor surgery were
also found to be lower than those in hospitals (O’Cathain et al., 1992). Similar
results were found for GPs providing diagnostic ultrasound (Wordsworth and
Scott, 2002). However, costs were not necessarily “saved” as the failure to divest
from hospital activity while increasing care provision in general practice led to
an overall increase in service capacity and costs, rather than a transfer from
secondary to primary care as was intended (Lowy et al., 1993).
Relocation
Adding specialists to general practice teams might be expected to enhance the
quality of care and improve access for patients. These benefits have only partially been realized in England, which has experimented with bringing hospital
physicians into general practice to provide “outreach” clinics. A systematic
review of research comparing outreach clinics with conventional hospital “outpatient” clinics found that outreach clinics were not cost-effective (Powell,
2002). Although outreach clinics enhanced patient access and satisfaction, clinical outcomes were similar and the costs of service delivery were higher because
of increased travel time for physicians and the smaller number of patients seen.
Other expected benefits, such as the dissemination of knowledge and skills from
hospital specialists to GPs, were not realized, as the two groups rarely interacted.
Mental health problems form a substantial part of the workload for primary
care teams in most countries. The United Kingdom and United States have
experimented with adding mental health counsellors to general practice teams
as a way of both enhancing the quality of care provision and reducing the
workload for GPs. A systematic review of available evidence suggests that counsellors are as effective as GPs in the management of patients with minor mental
Changing task profiles
157
illness – more effective in the sense that patients treated by counsellors
recovered more rapidly than did patients treated by GPs (Bower et al., 2002).
However, research evidence also shows that other anticipated benefits of attaching counsellors to general practice teams are not fully realized (Bower and
Sibbald, 2000). Specifically, the claims that counsellors might generally reduce
GP consultations, prescribing, and out-of-hours referrals for mental illness are
not well substantiated. Moreover, the costs of care were not lower when counsellors were substituted for GPs in the management of minor mental illness (Bower
et al., 2002).
Liaison
Using specialists to advise and support GPs in their care of patients is another
strategy for enhancing the skills of primary care professionals and hence the
quality of care provision. A number of models for liaison exist. GPs and hospital
specialists may enter into “shared care” agreements, which specify the division
of responsibility between GP and specialist in the joint management of a patient
which the GP would otherwise be unable or unwilling to manage alone. Shared
care arrangements have been evaluated in the management of chronic disease
(asthma and diabetes). The empirical evidence on cost-effectiveness is mixed.
For asthma, shared care used fewer resources (Grampian Asthma Study of Integrated Care, 1994; Eastwood and Sheldon, 1996). There were few differences in
clinical and health outcomes, but patients receiving shared care were less satisfied. In diabetes care, most studies reported that clinical and health outcomes
were similar to conventional hospital-based care (Greenhalgh, 1994). However,
the studies that included costs produced conflicting results. Overall, further
evidence still needs to be gathered as results seem to be specific to each context
and depend on good communication between specialists and generalists
(Eastwood and Sheldon, 1996; Hampson et al., 2002).
Alternatively, hospital specialists may undertake to improve general practice
skills through the provision of education or guidance centred on the care of
individual patients. A systematic review of available research into this model of
working concluded that “educational outreach” appeared “a promising
approach to modifying health professional behaviour” (Thomson O’Brien et al.,
2002). However, the evidence was not robust. Most evaluations of educational
outreach focused solely on prescribing behaviour. Only one study measured a
patient outcome and few examined cost-effectiveness. A systematic review of
research into liaison working in mental health also concluded that there was a
dearth of good evidence on which to base any firm conclusions (Bower and
Sibbald, 2000).
Acceptability to patients
How do patients view skill mix change? The answer depends on how their
experience of care relates to their expectations – and expectations may vary
among individuals, between countries and over time. Campbell et al. (2000)
158
Primary care in the driver’s seat?
propose that the quality of care for individual patients is determined by access
(Can patients get to health care?) and effectiveness (Is it any good when they get
there?). Effectiveness is additionally subdivided into clinical care and interpersonal care in order to reflect the importance of both for patients. Clinical care
is concerned with the technical quality of care delivery and asks whether service
provision accords with the best available evidence. Interpersonal care is concerned with the quality of the relationship between patient and practitioner,
which is integral to determining whether care is holistic, humane and personcentred.
Access
Patients report improved access to hospital specialists with shifted outpatient
clinics (Griffin and Kinmonth, 2000) and outreach clinics (Powell, 2002) in
general practice. Increased specialization among GPs and nurses within general
practice teams, together with the addition of other types of health professionals,
further increases the range of services and health care expertise available from
local general practices.
There are, however, notable disadvantages. Larger team size is known to
reduce personal continuity of care and patient satisfaction with access to care.
This is because patients find it more difficult to get an appointment with their
preferred doctor in larger general practices, although rapid access for acute problems may be easier. Patients favour small practices and full-time GPs, which is at
odds with the trend in many countries towards larger team size and part-time
work (Schers et al., 2002; Wensing et al., 2002).
Effectiveness
Patient assessments of the technical quality of care are limited by patients’
lack of medical knowledge, and hence rarely investigated. Professional assessments of the technical quality of care are reviewed above. Although there is a
dearth of good evidence, the findings suggest that the quality of care provision
is generally not diminished and may sometimes be enhanced through changes
in skill mix.
Patients’ assessments of the interpersonal quality of their care have been well
researched in the area of doctor-nurse substitution, but not other types of skill
mix. Systematic reviews suggest that patients rate the interpersonal skills of
nurses more highly than those of doctors (Horrocks et al., 2002). The reason for
this is unclear and may relate to a number of factors, including nurses’ gender,
social status, and consultation length. The great majority of nurses are female
and females are often regarded as more “caring” than males (Gray, 1982). Nurses
tend to have a lower social status than doctors, making them more approachable to patients. In addition, nurses tend to have longer consultation times than
doctors and patient satisfaction tends to be higher with longer consultations
(Freeman et al., 2002). It may also be true that nurses, by virtue of their training,
have better developed interpersonal skills than doctors.
Changing task profiles
159
High satisfaction with nurse care does not, however, mean that patients
inevitably prefer nurses to doctors. Patient preferences in most studies are
mixed, with some patients preferring to see nurses while others prefer to see
doctors (Venning et al., 2000; Horrocks et al., 2002). Preference may be related to
the nature of the presenting problem. Laurant and colleagues (2000) found that
patients in the Netherlands preferred to see their GP for most aspects of care,
although they did favour the nurse for health education/advice and regular
health checks. Others have found that nurses are acceptable when the patient
believes their problem to be “minor” or “routine” but that doctors are preferred
when the problem is “serious” or “difficult” (Drury, 1988).
Impact on professionals
Changing the way people work can win commitment from those professionals
for whom new opportunities are created (Leverment et al., 1998). Individuals
may feel better supported when they work in teams and good support can offset
the stress of high job demand (Calnan et al., 2000). However, restructuring jobs
may create losers as well as winners. For example, GPs and practice nurses may
view nurse practitioners as unwelcome competitors (Vogel, 1998).
In the context of staff shortages, the reorganization of work can be perceived
as work intensification (Leverment et al., 1998) and can lead to working longer,
more unsocial hours on a routine basis in order to fulfil new remits (Adams et al.,
2000). The transfer of services from hospitals to general practice will increase
the primary care workload unless it is adequately resourced (Pedersen and Leese,
1997; Scott and Wordsworth, 1998). Adding nurses to general practice teams
may not have the intended effect of reducing GPs’ workload (Laurant et al.,
2004).
Larger team size increases transaction costs because staff need to spend
increasing amounts of time conferring with each other, decreasing the amount
of time available for direct patient care (Barr, 1995). A critical point is reached
when transaction costs outweigh the benefits of working in groups. Shared
patient record systems, to which all team members may contribute and withdraw information, have been advocated as one means to reduce transaction
costs (Rigby et al., 1998). Electronic medical records are the preferred option as
information can be transmitted quickly to whomever and wherever it is needed.
However, developments in this area are often inhibited by the high initial cost
of computerization, the incompatibility of computer systems used by different
providers, and concerns about the confidentiality of patient information
(Keeley, 2000).
Good teamwork is associated with better quality of care (Goni, 1999; Bower
et al., 2003) but can be difficult to achieve (West and Poulton, 1997). Redrawing
the boundaries between professional groups and established job roles demands
excellent human resource management skills. Consultation with key stakeholders, good support for middle managers, and continuity of leadership
may help to promote success. Clarification of job descriptions and the introduction of induction programmes (Koperski, 1997) as well as specific training in
teamwork (Long, 1996) may also prove helpful. Where steps are not taken
160
Primary care in the driver’s seat?
actively to manage the transition to multiprofessional work or teamwork,
tensions are likely to arise and the desired benefits may not be realized (Landau,
2001).
Conclusion
Skill mix both determines, and is determined by, organizational systems and the
wider health care economy. The “correct” mix of tasks and skills that primary
care professionals should undertake is therefore heavily dependent on context.
Skill mix change in one part of the system may impact on other parts with
unforeseen consequences. When considering changes to task profiles and skill
mix, policy-makers need to weigh up and make trade-offs between potential
costs and benefits. For example, larger primary care teams may enhance efficiency through improvements in the quality of clinical care, economies of
scale and scope, and reduced waiting times for patients. However, this may
also increase transactions costs and reduce the continuity of care and patient
satisfaction with the interpersonal quality of care.
Policy-makers who assume that task profiles and skill mix can be changed
within existing budgets are ignoring the complex realities of health professionals’ work. Changing existing tasks and skill mix is likely to increase costs in
the short term because services are likely to expand into the new area and existing services will contract much more slowly, if at all. It will not be until the
longer term, where new tasks and roles are embedded within new jobs and
institutions and where training programmes are changed to reflect these new
roles, that gains in efficiency will be forthcoming.
The change in tasks of primary care physicians, and the extent to which they
are generalists or are able to specialize, also highlights important trade-offs.
Primary care generalists are thought to be the linchpin of a cost-effective health
care system as they act as gatekeepers to specialist care. However, where incentives exist for primary care physicians to specialize, what effect will this have on
access, on the gatekeeper role, on continuity of care, and on similar hospitalbased services? Some countries, with strong primary care-centred health care
systems are encouraging their generalist GPs to become more specialized (e.g.
the United Kingdom). Other countries, with a strong emphasis on specialist
care, are seeking to replace specialists with generalist GPs (e.g. Estonia). This
emphasizes the role of context in that these opposite reforms may be efficient in
their respective countries.
Whether skill mix change is the most appropriate solution to a perceived
problem will depend on the particular context in which change is contemplated. Policy-makers and managers need to carefully analyse the nature of the
“problem” they wish to resolve and identify appropriate solutions, taking into
consideration the potential wider and long-term effects on the system of care.
Optimum team size and composition will vary from country to country and
over time, depending on the available mix of health personnel, the labour
economy and the priorities accorded to different aspects of the quality of care
provision.
Changing task profiles
161
References
Adams, A., Lugsden, E., Chase, J., Arber, S. and Bond, S. (2000). Skill-mix changes and
work intensification in nursing, Work, Employment and Society, 14: 541–555.
Atkin, K. and Lunt, N. (1996). Negotiating the role of the practice nurse in general
practice, Journal of Advanced Nursing 24: 498–505.
Atkin, K., Hirst, M., Lunt, N. and Parker, G. (1994). The role and self-perceived training
needs of nurses employed in general practice: observations from a national census of
practice nurses in England and Wales, Journal of Advanced Nursing 20: 46–52.
Baker, D. and Klein, R. (1991). Explaining outputs in primary health care: population and
practice factors, British Medical Journal 303: 225–229.
Barr, D.A. (1995). The effects of organizational structure on primary care outcomes under
managed care, Annals of Internal Medicine 122: 353–359.
Boerma, W.G.W. (2003). Profiles of General Practice in Europe. Utrecht: NIVEL.
Bower, P. and Sibbald, B. (2000). Systematic review of the effect of on-site mental health
professionals on the clinical behaviour of general practitioners, British Medical Journal
320: 614–617.
Bower, P., Rowland, N., Mellor Clark, J., Heywood, P., Godfrey, C. and Hardy, R. (2002).
Effectiveness and cost effectiveness of counselling in primary care. Cochrane Review, in:
The Cochrane Library, Issue 1, Oxford: Update Software.
Bower, P., Campbell, S., Bojke, C. and Sibbald, B. (2003). Team structure, team climate and
the quality of care in primary care: an observational study, Quality and Safety in Health
Care 12: 273–279.
Buitink, J.A. (ed.) (2000). De eerstlijns geestelijke gezondheidszorg in perspectief [Primary
mental health care in perspective]. Utrecht/Amsterdam: LHV, LVE, VOG.
Calnan, M., Wainwright, D., Forsythe, M. and Wall, B. (2000). Health and Related Behaviour
within General Practice in South Thames. Canterbury: Centre for Health Services Studies,
University of Kent.
Campbell, S.M., Roland, M. and Buetow, S. (2000). Defining quality of care, Social Science
and Medicine 51: 1611–25.
Chambers, R. and Campbell, I. (1996). Gender differences in general practitioners at work,
British Journal of General Practice 46: 291–93.
Charlton, I., Charlton, G., Broomfield, J. and Mullee, M.A. (1991). Audit of the effect of a
nurse run asthma clinic on workload and patient morbidity in general practice, British
Journal of General Practice 41: 227–231.
Commonwealth Department of Health and Family Services (1996). The organisation of
general practice, in General Practice in Australia: 1996: 107–134, Canberra: Commonwealth Department of Health and Family Services.
De Vries, I. (2001). Praktijkondersteuning (2) [Support in general practice (2)] Medisch
Contact 56: 1402.
Department of Health (2000). The NHS Plan 2000. London: Department of Health.
Department of Health (2002). Extending Independent Nurse Prescribing within the NHS in
England. London: Department of Health.
Department of Health and Royal College of General Practitioners (2002). Implementing a
Scheme for General Practitioners with Special Interests. London: Department of Health.
Diabetes Integrated Care Evaluation Team (1994). Integrated care for diabetes: clinical,
psychosocial, and economic evaluation, British Medical Journal 308: 1208–12.
Drury, M., Greenfield, S., Stillwell, B. and Hull, F.M. (1988). A nurse practitioner in general
practice: patients perceptions and expectations, Journal of the Royal College of General
Practitioners 38: 503–505.
Eastwood, A.J. and Sheldon, T.A. (1996). Organisation of asthma care: what difference
does it make? A systematic review of the literature, Quality in Health Care 5: 134–143.
162 Primary care in the driver’s seat?
Ebrahim, S. and Davey Smith, B. (2002). Multiple risk factor interventions for primary
prevention of coronary heart disease (Cochrane Review), in The Cochrane Library;
Issue 3. Oxford: Update Software.
Family Heart Study Group (1994). Randomised controlled trial evaluation cardiovascular
screening and intervention in general practice: principal results of British Family
Heart Study, British Medical Journal 301: 1028–1030.
Finn, L. and Crook, S. (1998). Minor surgery in general practice – setting the standards,
Journal of Public Health Medicine 20: 169–174.
Freeman, G.K., Horder, J.P., Howie, J.G.R. et al. (2002). Evolving general practice consultation in Britain: issues of length and context, British Medical Journal 324: 880–882.
Gibbs, T., Mulka, O., Zaremba, E. and Lysenko, G. (1999). Ukranian general practitioners;
the next steps, European Journal of General Practice 5(1): 29–32.
Godber, E., Robinson, R. and Steiner, A. (1997). Economic evaluation and shifting the
balance towards primary care: definitions, evidence and methodological issues,
Health Economics 6: 275–294.
Goni, S. (1999). An analysis of the effectiveness of Spanish primary health care teams,
Health Policy 48: 107–117.
Grampian Asthma Study of Integrated Care (GRASSIC) (1994). Integrated care for asthma:
a clinical, social and economic evaluation, British Medical Journal 308: 559–564.
Gray, J. (1982). The effect of a doctor’s sex on the doctor-patient relationship, Journal of the
Royal College of General Practitioners 32: 167–169.
Greenhalgh, P.M. (1994). Shared Care Diabetes: A Systematic Review. Occasional Paper 67.
London: Royal College of General Practitioners.
Griffin, S. and Kinmonth, A.L. (2000). Diabetes Care: The Effectiveness of Systems for Routine
Surveillance for People with Diabetes. Cochrane Review, in The Cochrane Library, Issue 1,
Oxford: Update Software.
Hampson, J.P., Roberts, R.I. and Morgan, D.A. (2002). Shared care: a review of the literature, Family Practice 19: 53–56.
Hirst, M., Atkin, K. and Lunt, N. (1995). Variations in practice nursing: implications
for family health services authorities, Health and Social Care in the Community, 3:
83–97.
Hooker, R. and Cawley, J. (2003). Physician Assistants in American Medicine, 2nd edition.
New York: Churchill Livingstone.
Horrocks, S., Anderson, E. and Salisbury, C. (2002). Systematic review of whether
nurse practitioners working in primary care can provide equal care to doctors, British
Medical Journal 324: 819–823.
Hutchinson, L., Marks, T. and Pittilo, M. (2001). The physician assistant: would the
US model meet the needs of the NHS? British Medical Journal 323: 1244–1247.
Keeley, D. (2000). Information for health – hurry slowly, British Journal of General Practice
50: 267–8.
Koperski, M. (1997). Nurse Practitioners in General Practice: Strategies for Success. London:
Camden and Islington Health Authority/London Implementation Zone Educational
Initiative.
Landau, J. (2001). Organising General Practitioners into Group Practices. The City of and
Province of Milan, Italy. Milan: Bocconi University.
Laurant, M., Hermens, R., Braspenniing, J. and Grol, R. (2000). De huisarts en de praktijkverpleegkundige in Midden Brabant. Eindrapport: Resultaten effect- en procesevaluatie. [The
general practitioner and the nurse practitioner in Midden Brabant. Final report:
results from the effect and process evaluation] Nijmegen: WOK/UMCN.
Laurant, M.G.H., Hermens, R.P.M.G., Braspenning, J.C.C., Sibbald, B. and Grol, R.P.T.M.
(2004). Impact of nurse practitioners on workload of general practitioners: randomised controlled trial, British Medical Journal 328(7445): 927.
Changing task profiles
163
Leverment, Y., Ackers, P. and Preston, D. (1998). Professionals in the NHS – a case study
of business process re-engineering, New Technology, Work and Employment 13: 129–39.
Long, S. (1996). Primary health care team workshops, Journal of Advanced Nursing 23:
935–41.
Lowy, A., Brazier, J., Fall, M., Thomas, K., Jones, N. and Williams, B.T. (1993). Minor
surgery by general practitioners under the 1990 contract: effects on hospital workload,
British Medical Journal 307: 413–417.
Ministerie van Volksgezondheid, Welzijn en Sport, Zorgverzekeraars Nederland and
Landelijke Huisartsen Vereniging (1999). Convenant LHV, ZN en VWS inzake de versterking van de huisartsenzorgal [Covenant LHV (National Association General Practitioners), ZN (National Insurance Company) and VWS (Department of Health)
concerning reinforcement of primary health care ]. Den Haag/Utrecht: 30 June 1999.
Mittman, D.E., Cawley, J.F. and Fenn, W.H. (2002). Physician assistants in the United
States, British Medical Journal 325: 485–487.
Nijland, A., Groenier, K., Meyboorm-de Jong, B., De Haan, J. and Van der Velden, J. (1991).
Determinanten van het delegeren van (medisch-technische) taken aan de praktijkassistente [Determinants of substitution of (medical) tasks to a practice nurse], Huisarts
en Wetenschap 34: 484–487, 499.
O’Cathain, A., Brazier, J.E., Milner, P.C. and Fall, M. (1992). Cost-effectiveness of minor
surgery in general practice: a prospective comparison with hospital practice, British
Journal of General Practice 42: 13–17.
OXCHECK Study Group (1995). Effectiveness of health checks conducted by nurses
in primary care: final results of the OXCHECK study, British Medical Journal 310:
1099–1104.
Pedersen, L.L. and Leese, B. (1997). What will a primary care led NHS mean for GP
workload? The problem of the lack of an evidence base, British Medical Journal 314:
1337–1341.
Powell, J. (2002). Systematic review of outreach clinics in primary care in the UK, Journal
of Health Services Research and Policy 17: 177–183.
Renders, C.M., Valk, G.D., Griffin, S.J., Wagner, E.H., Eijk, J.T. and Assendelft,
W.J.J. (2001). Interventions to improve the management of diabetes in primary care,
outpatient, and community settings, Diabetes Care 24: 1821–1833.
Rigby, M., Roberts, R., Williams, J. et al. (1998). Integrated record keeping as an essential
aspect of a primary care led health service, British Medical Journal 317: 579–582.
Schers, H., Webster, S., Van den Hoogen, H., Avery, A., Grol, R. and Van den Bosch, W.
(2002). Continuity of care in general practice: a survey of patients’ views, British
Journal of General Practice 52: 459–462.
Scott, A. (1996). Primary or secondary care? What can economics contribute to evaluation
at the interface? Journal of Public Health Medicine 18: 19–26.
Scott, A. and Wordsworth, S. (1998). The effects of shifts in the balance of care on general
practice workload, Family Practice 16: 12–17.
Scott, A., Currie, N. and Donaldson, C. (1998). Evaluating innovation in general practice:
a pragmatic framework using programme budgeting and marginal analysis, Family
Practice 15: 216–22.
Sekcenski, E., Sansom, S., Bazell, C., Salmon, M. and Mullan, F. (1994). State practice
environments and the supply of physician assistants, nurse practitioners, and
certified nurse-midwives, New England Journal of Medicine 331: 1266–1271.
Spitzer, W.O., Sackett, D.L., Sibley, J.C. et al. (1974). The Burlington randomized trial of
the nurse practitioner, New England Journal of Medicine 290: 251–256.
Thomson O’Brien, M.A., Oxman, A.D., et al. (2002). Educational outreach visits: effects on
professional practice and health care outcomes. Cochrane Review, in The Cochrane
Library, Issue 3. Oxford: Update Software.
164 Primary care in the driver’s seat?
Venning, P., Drurie, A., Roland, M., Roberts, C. and Leese, B. (2000). Randomised
controlled trial comparing cost effectiveness of general practitioners and nurse
practitioners in primary care, British Medical Journal 320: 1048–53.
Vogel, J. (1998). NVDA wil meer overleg over komst praktijkverpleegkundige. [NVDA
wants to confer about the entry of nurse practitioners], De huisarts in Nederland 12:
13–15.
Wensing, M., Vedsted, P., Kersnik, J. et al. (2002). Patient satisfaction with availability of
general practice: an international comparison, International Journal for Quality in
Health Care 14: 111–18.
West, M.A. and Poulton, B.C. (1997). A failure of function: teamwork in primary health
care, Journal of Interprofessional 11: 205–216.
Wilson, A., Pearson D. and Hassey, A. (2002). Barriers to developing the nurse practitioner
role in primary care – the GP perspective, Family Practice 19: 641–46.
Wordsworth, S. and Scott, A. (2002). Ultrasound scanning by general practitioners: is it
worthwhile? Journal of Public Health Medicine 24: 89–94.
chapter
nine
Changing professional roles
in primary care education
Jan Heyrman, Margus Lember,
Valentin Rusovich and Anna Dixon
General practice/family medicine has a central role in health care, helping to
keep the focus on the needs of the patient. Both policy experts (Starfield, 1998)
and official organizations (WONCA/WHO, 2002), support this view, believing
that the balance in health care should shift from supply-driven development to
needs and community-driven priority setting. Given that the main challenge
for health care is to find and maintain an appropriate balance between quality,
equity and cost-effectiveness, it is natural that primary care (PC) is expected to
make a central contribution (Boelen, 1999).
Teaching, training and reaccreditation are important instruments in the
adaptation of primary care professionals to these new challenges. This chapter
evaluates the evolution and impact of professional training in strengthening
the role of PC within European health care systems. Education can be seen as
the cornerstone of professional self-regulation. We also analyse the role of professional organizations in the development of a new role for PC. To place PC
in the driver’s seat of the health care system requires professional leadership
and support. Professional associations and colleges can play a key role in the
critical field of education and training, and more generally, in strengthening the
political and professional position of PC.
Main actors and stages in PC education
In 1999, EURACT (European Academy of Teachers in General Practice, the educational board of WONCA-Europe) collected information on the impact of the
central players, governments, medical professionals and scientific groups and
universities on the different educational stages of the GP profession (EURACT,
1999). The enquiry covered basic medical education, internship, specific training
166
Primary care in the driver’s seat
and continuous medical education (CME) in 27 European countries. This
chapter maps the power positions of different actors at different stages of the
process of medical education and training based on the evidence generated by
EURACT and other sources.
Professional organizations
The history and influence of the professional bodies of GPs is not comparable
between western and eastern Europe. In some countries of the newly independent states (NIS) of the former USSR they have existed for less than three–five
years, in the Baltic countries they were established more than 10 years ago, and
in some other countries of central and eastern Europe even longer ago. In most
of western Europe, PC professional associations were created from the 1960s
onwards. Very little comparative evidence on professional associations has been
gathered across Europe to date.
In most European countries professional organizations are the main governing
body in continuous medical education and lifelong learning. Undergraduate
education is mainly in the hands of universities, but professional organizations
also have some influence in the content as well as in the recruitment for internship positions. In between is the crucial period of specialty training, which in
four European countries (including Norway and the United Kingdom) is the
responsibility of the profession, but in most countries (10, including Belgium,
Finland and the Netherlands) this training is organized by academic university
departments. In Denmark the state or municipalities have this responsibility.
To complete the picture of diversity, in some central, eastern and southern
European countries, specialty training in general practice is still in the ‘start-up’
phase and professional bodies of GPs are weak or absent.
Universities and ministries of education
Basic medical education in Europe is largely the responsibility of ministries and
departments of education, with universities providing most core medical training (see Table 9.1). Progressive at the scientific level but rather conservative at the
level of health policy, they are generally characterized by a strong dominance of
specialist-centred care. Universities and medical schools are also the most
important provider of postgraduate specialty training in 10 countries, while
independent postgraduate schools are responsible for this in four countries.
Ministries of health
Health ministries are the authority for PC specialist training in most European
countries. In more than half of Europe they control CME as well. In all countries
where a formal recertification procedure has been established, the health
ministries and medical colleges are responsible. In several European countries,
the health ministry is also involved in human resource planning in health care.
Changing professional roles in primary care education 167
Table 9.1 The role of government, professionals and universities in PC education
Belgium
Bosnia and
Herzegovina
Croatia
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Israel
Italy
Lithuania
the Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
United Kingdom
Specialist
training, ST:
PC setting
ST: Hospital
setting
CME
accreditation
CME providers
GP
U
GP
H
G
G
U + P + S + PI
U
U
PS
S
U
U
U
P
GP
U
GP
U
PS
U
GP
P
PS
GP
GP
GP
U
GP
G
P
n.a.
GP
U + H + GP
H
H + GP
H
U
U+H
P
H
U+H
S
H
PS
U
GP
H
H + GP
H
S
PS
H
GP
G
H
U+H
S
G
G
P
n.a.
G
G
G
G
G
G
n.a.
G
G
G
G
n.a.
G
PS
G
n.a.
G
G
G
n.a.
G
Many different
n.a.
Many different
U
U + S + G + PI
S
P+S+H
P + PI
U
S
U + HI
P + PI
U
P+S
P
Many different
Many different
GP
PS
U + P + PI
S + U + PI
G
P+S+H
P
Many different
Source: EURACT (1999).
* G=Governement (national or county level), P=Professional groups, S=Scientific societies
(including colleges and GP educational structures), U=Universities as a faculty, GP=GP
departments, PS=Postgraduate schools, HI = Health Insurance, PI=Pharmaceutical Industry,
n.a.= not available
The number of health professionals and medical doctors by subspecialties is
a critical variable in allocating resources and controlling expenditure (see
Table 9.2). The number of GPs versus specialists is also important in tracking
shifts in the balance of health care towards PC professions.
Private training bodies and the pharmaceutical industry
In the field of PC specialist training, some additional providers of education,
such as independent GPs or international support programmes were present.
168 Primary care in the driver’s seat
Table 9.2 Human resources in PC across Europe
Albania
Austria
Belgium
Bosnia and
Herzegovina
Croatia
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Israel
Italy
Lithuania
the Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
United Kingdom
Human resources in PC practices (% of
total active GPs)
PC over total medical
graduates
Trained GP
Inservice
training GP
Nontrained
GP
Total annual
medical
graduates
GP annual
graduates
(% of
total)
3
65
100
1
32
34
0
n.a.
65
1
0
99
175
1100
700
120
10
64
43
25
26
99
100
80
50
40
72
100
96
45
33
100
71
85
51
29
100
16
100
60
50
80
98
2
75
n.a.
0
0
n.a.
0
0
0
0
0
0
0
n.a.
29
0
0
0
n.a.
n.a.
0
n.a.
0
0
0
0
0
74
1
0
20
50
60
28
0
4
55
67
0
0
15
49
71
0
84
0
40
50
20
2
98
25
400
1000
600
85
500
4000
10000
2000
1000
n.a.
800
2000
650
1500
550
2500
1100
2500
700
150
5000
600
600
4500
4500
3
7
30
21
18
50
18
10
10
(75 GPs)
25
18
31
24
36
40
36
16
11
27
38
17
n.a.
3
44
Note: n.a. = not available. When ‘In service training GP’ data were not available, they are
supposed to be included in “Trained GP” data.
Source: EURACT (2004).
The CME landscape proved the most diverse (EURACT, 1999), as institutions
ranging from universities to independent private institutions were involved in
professional education. In many countries the major role of the pharmaceutical
industry also was notable.
Changing professional roles in primary care education 169
Four models of governance in Europe
Four models of GP education have been proposed based on EURACT (1999)
data. However, no country exactly fits the ideal models and some do not fit any
model very well.
Regulation-dominated model
This model, existing predominantly in Austria, Germany and some CEE countries (Croatia, Slovenia), is characterized by strong and independent universities
and/or an important role for medical associations. Strong regulations regarding
basic education and CME are also present. Medical associations also have a
central role in postgraduate medical education.
Profession-dominated model
This model, founded in Ireland and the United Kingdom, is characterized by a
strong role for GP professional organizations, which are independent and have
developed their own pedagogical method. The role of the universities is smaller
and departments of general practice usually have strong links with professional
organizations. The dominant player in general practice education is the professional organization.
Science-dominated model
The science dominated model exists in the Netherlands and some other
northern European countries (e.g. Estonia, Finland). It is characterized by the
predominant role of universities, which are responsible for most undergraduate
and much postgraduate instruction.
Liberal model
This model exists in Belgium, France, Greece and Italy. It is characterized by
independent institutions at the postgraduate level that have links with professional organizations. There is a wealth of different professional and training
organizations, which sometimes compete among themselves.
The role of international organizations
The two key international organizations active in European health care are the
European Office of the World Health Organization (WHO-Europe), and the
European Union (EU). It is worth mentioning the important role given to PC in
the Health for All strategy designed by WHO-Europe in 1983, as well as the
170
Primary care in the driver’s seat
critical landmark of 1986, when an EU directive was approved recommending
the establishment of PC as a specialty in Europe. In 1995, UEMO (Union européen
des médecins omnipraticiens), the GPs trade union, succeeded in making the EU
accept compulsory specialty training for a minimum of two years, which will be
expanded to three years in 2006 (UEMO, 1995). In the early 1990s, the WHO
started the programme ‘Changing Medical Education’, which aimed at shifting
from ‘problem-based’ to ‘community-based’ education. In 1998 it obtained
approval from the EU for a document called ‘Framework for general practice/
family medicine in Europe’ presenting its clear support to PC education development and pointing out the necessary structural conditions and improvements
required to realize this goal (WHO, 1998).
Other prominent international organizations active in the European PC
sector are the PC professional association WONCA (World Organization of
National Colleges and Academies) and its branch WONCA Europe. In June 2002
WONCA developed a condensed document which defined the core competencies of GPs and their role in the health care system. Impressively, WONCA also
succeeded in having all European countries adopt it (WONCA Europe, 2002). In
2004 EURACT proposed its first version of ‘The Educational Agenda of GP/FM’,
in which six core competencies were translated into learning objectives;
consequences for educational methods, assessment methods were outlined; and
a time frame for integration into the educational curriculum was set (Heyrman,
2004).
European support programmes for the development of PC education in CEE
and NIS countries are also of vital importance. In the 1990s there were several
initiatives involving the World Bank, EU Phare, the WHO, USAID and the Open
Society Institute. These provided a wide range of support policies. Their
most remarkable achievement has been their capacity-building investment in
training people to be leaders of PC education in these countries.
The development of education for family medicine/general
practice in Europe
Historically in Europe, two basic models of FM/GP were in use. In France and
Great Britain the education of doctors in the nineteenth century was concentrated in hospitals, while in Germany and Scandinavia it was provided in
universities (Vuori, 1979; Ko Ko, 1994). Priorities were set by hospitals and
science, not by patients or PC. In the United States Abraham Flexner prepared
an optimal medical curriculum with a sizeable basic sciences component
in 1910.
After the Second World War a massive fragmentation of medical practice
into different specialties began. The family doctor remained nonspecialized.
PC professionals slowly started to create a speciality as an innovative type of
supra-specialist (Starfield, 1998). The first chair of general practice in Europe
was created in the United Kingdom in Edinburgh in 1963, followed in 1966
by the Netherlands, and in 1968 by Belgium. These academics created the
Leeuwenhorst group, which defined a very wide task profile for PC, ranging
from prevention to terminal care. ‘Co-operation with other colleagues, medical
Changing professional roles in primary care education 171
and non-medical’ and ‘a professional responsibility towards the community’
were mentioned as crucial in their statement on The General Practitioner in
Europe, which became a central element in many curricula of general practice/
family medicine throughout Europe (Leeuwenhorst Group, 1974; New Leeuwenhorst Group, 1981). By the early 1990s, most PC doctors were already specialists in many western European countries (Boerma and Fleming, 1998), and
PC was granted a prominent role within the health care systems in several taxfunded countries as well as the Netherlands.
Developments in eastern and central Europe, with Semashko-type systems,
initially went in the opposite direction, with PC having an increasingly subordinate role to subspecialist care. In the late 1980s/early 1990s in most CEE
countries it became obvious that specialization had exhausted its limits.
More efficient use of resources in the health care system in a time of economic
decline was the argument used by international organizations and national
politicians to promote general practice (Schepin et al., 1996). At the universities,
departments of family medicine were created and selected professionals
were sent to western Europe to become PC instructors (Lember, 1996, 2002;
Kuznethova et al., 2000).
The role of PC in undergraduate education
General practice/family medicine has a central place in undergraduate medical
teaching. As this focus seeks to introduce the community dimension into basic
medical education, a first challenge is to obtain an appropriate place as a
department in the faculty structure. An enquiry carried out by EURACT in 1997
covered 297 medical faculties, in 26 European countries. There was undergraduate teaching of family medicine in all countries, but only in 191 faculties.
General practice was taught at every medical school in 18 out of the 26
countries. The extent and methods of education were quite different. In some
countries general practice was an obligatory subject, in others it was not. The
bulk of undergraduate teaching in general practice was done in clinical attachments to GPs in the community in most medical schools. Final examinations
had been introduced in 14 countries. New, active methods of instruction for the
medical undergraduate curriculum have also been developed.
Some documents elaborate on the nature of the GP contribution to basic
medical education. The Leeuwenhorst group issued the pioneering statement
on ‘the contribution of the General Practitioner to undergraduate Medical Education’ which stressed the integral, person-centred (versus illness or organcentred) focus of PC (Leeuwenhorst Group, 1977), and its key role within health
care as a profession. From then on, a debate opened on the specific skills or
competencies which should be taught by PC undergraduate departments. A
publication by Dundee University summarizes the results of this debate in a
model for the specification of learning outcomes (Harden et al., 1999), which
can be applied to GPs:
• clinical care focus on common, most prevalent diseases;
• teaching communication skills: the key to the patient-doctor relationship;
172
Primary care in the driver’s seat
• teaching organizational skills: GPs are resource managers for their patients;
• teaching professional values: GPs best placed to discuss value choices;
• teaching professional growth: surveying community and patient needs.
An interesting Dutch document (Grundmeijer and Rutten, 1996) defines the
possible contribution of PC in the ‘180 educational endpoints and the 250 problem areas of basic medical education’. It classifies educational areas in three
groups:
• content that is best taught by the PC department;
• content that is best taught where PC teaching is by specialist departments;
• content that does not pertain to PC.
Specialist training in general practice/family medicine
A recent overview (EURACT, 2004) shows that European regulations clearly are
effective: as of the study’s date (2004), in all of the 15 EU Member States and
also in at least 13 of the EU accession and pre-accession countries, postgraduate
specialist training for general practice/family medicine has been introduced
for an average of three years, which is the recommended minimum time frame
in Europe since February 2001 (see Table 9.3). The balance between training
in a GP setting versus a hospital setting is different in each country. It ranges
from three years in a GP setting in Bosnia and Herzegovina to four and a half
out of five specialty years in a hospital setting in Switzerland. Almost 40,000
specialist GPs are trained and 10,000 finish the specialty training each year. In
two thirds of these countries, there is a local handbook on family medicine
available.
The development of PC specialists in Europe has not been an easy task. The
design of academic education programmes had to be paralleled by the building
of ‘in-service training programmes’ which would cater to junior doctors as well
as enhance the skills of non-trained GPs active in the field. In northern Europe
this process started during the 1970s, in southern Europe during the 1980s, and
in central and eastern Europe from the 1990s onwards (see Box 9.1).
These developments are surely positive steps in the right direction, but
unfortunately often represent more model practices than common examples in
many European countries. The quality and the content of the training varies a
great deal across Europe. In several EU countries, especially in ex-Semashko
countries, there are not enough teaching practices for young GPs and education
is still to a great extent hospital-based, with many educational topics delegated
to the specialist university departments (Shabrov et al., 2001). In a period of
great change these kinds of problems are inevitable. The task of the first chairs in
general practice in the region has been to gain acceptance to implement
changes. Some authors reported educational changes and relevant research in
these countries to be of great importance and interest (Barr and Schmid, 1996).
In a next generation, academic GPs could be recruited from the first generation
of well-trained GPs.
Changing professional roles in primary care education 173
Table 9.3 Specialty training in European countries: duration (years) by setting
Albania
Austria
Belgium
Bosnia and
Herzegovina
Croatia
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Israel
Italy
Lithuania
the Netherlands
Norway
Poland
Portugal
Romania
Russian Federation
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
United Kingdom
Duration
GP setting
Hospital
setting
Public
Health
Content
explicit
2
3
3(1+2)
3
0.2
0.5
2.5
3
1.6
2.5
0.5
0
0.2
0
0
0
N
N
N
Y
3
3
3.5
3
6
3
5
4
5
3
4
2
3
3
5
4
3
3
2
3
4
3
5
5
3
3
1
0.5
1
1.5
4
0.5
2
0.9
3.5
1
2
0.5
0.5
2
4
2
2
1.25
0.2
0.5
2
1.5
3
0.5
0
1
1.2
1.3
2.5
1.5
2
2.5
3
3.1
1
2
2
1.5
2.5
0.8
1
2
1
1.66
1.8
2.5
2
1.5
2
4.5
3
2
0.6
0
0
2 weeks
0
0
0
0
0.5
0
0
0.5
0
0
0.5
0
0
0.09
60 hours
0
0
seminars
0
0
0
0
Y
N
N
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Y
Y
N
N
N
Y
Y
N
Y
N
N
Y
Source: EURACT (2004).
Box 9.1 Retraining in CCEE
With the help of international projects, in different CEE regions the complex integrated process of retraining and structural innovation in PC
could be accelerated. For example, in Belarus in 1998–2001, a network of
better equipped PC practices was created in the Minsk region supported by
the Dutch-Belarussian MATRA project. Model practices were adopted in
which young GPs could ‘learn by doing’ under the supervision of more
skilled GPs (Rusovich et al., 2000).
174 Primary care in the driver’s seat
Accreditation and reaccreditation
The combination of declining public trust in the professions and rapid advances
in medical practice has led to a demand for doctors to be recertificated. Society
has the right to ask for guarantees. Governments in most countries have introduced or are considering implementation of a system with different but parallel
names like revalidation, reregistration, relicensing or recertification for doctors.
Introducing recertification is not only a technical issue concerned with how to
recertify, how often and by whom, but it is also a political issue concerned with
the relationship between individual professionals, professional bodies, health
care providers and purchasers, regulatory authorities, the state and the public.
The traditional assessment tools of recertification are credits assessment, peer
review and external inspection or audit. An alternative would be examination, a
simpler process to administer but with less external validity. An examinationbased approach has been criticized for creating assessment-driven learning
(Jolly et al., 2001). In the United States, where mandatory recertification was
implemented as early as 1969 by the American Board of Family Practice, difficulties have been reported with devising fair assessment measures based on patient
outcomes (Norcini, 1999). It seems there is no proven method for demonstrating
physician competence and professionalism (Smith, 2000).
The table below provides an overview of the recertification of GPs in
Europe (Table 9.4). It identifies the objectives of recertification, considers the
most appropriate methods and finally reflects on the political issues associated
with the implementation of recertification. It also deals with newer arrangements such as Continuous Professional Development Planning, which uses
newer assessment tools like the personal learning agenda and the individual
portfolio.
Objectives, methods and responsible bodies
Recertification firstly aims to ensure that doctors are in a fit state of physical and
mental health to practice without endangering their patients. This issue is pertinent in light of studies that highlight problems of alcoholism, drug addiction
and stress among health professionals (Firth-Cozens and Greenhalgh, 1997;
Weir, 2000; Gossop et al., 2001). Also, when doctors are allowed to practice
beyond retirement age, it is important to ensure they are still capable of practicing medicine. Second, recertification aims to ensure doctors are ‘up-to-date’.
In the context of rapid developments in medical technology, recertification is
also concerned with ensuring that doctors’ practice is based on state-of-the-art
medical knowledge. Third, recertification places increasing emphasis on quality
assurance and health care standards. One of the goals is to identify at an early
stage those doctors who are underperforming. Other objectives of recertification
might be to ensure that doctors abide by high ethical standards, improve patient
care and enhance continuing professional development (Buckley, 1999). There
may also be unexpressed objectives, for example, the profession may introduce
recertification in an attempt to maintain its position as well as control over
entry.
Changing professional roles in primary care education 175
Table 9.4 Regulation of recertification in Europe
Belgium
Croatia
Czech Republic
Estonia
Hungary
Ireland
Israel
Italy
Lithuania
the Netherlands
Norway
Poland
Romania
Slovakia
Slovenia
Spain
Switzerland
Turkey
United Kingdom
Procedure
developed
Frequency/
years
Responsible
body *
Credit
system
Peer group
evaluation
Examination
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
N
Y
Y
Y
N
N
N
Y
3
6
5
5
5
G+P+U
P
P
G+P
U
5
5
5
5
P
G
G
P
G
5
5
7
S
P
P
5
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
N
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
N
*Government (G), Professional (P), scientific societies (S) or Universities (U).
Source: EURACT (2004).
There are different responsibilities associated with the recertification process:
setting standards, accrediting CME activities, providing CME activities, inspection and peer review, remedial training, and recertification. For each of these a
clear division of responsibility needs to be made to ensure coordination and
mutual recognition.
The frequency of recertification depends on a number of factors: whether
measures are in place to identify poor practice, whether a doctor has previously
failed recertification, the rapidity of developments in a particular field, whether
resources are available for recertification, and whether practice is supported by
other quality initiatives (e.g. compulsory CME, practice guidelines, prescription
information). Some of these factors may justify differential frequency of recertification for different specialties, for doctors at different stages in their careers
and for different doctors depending on their background. In practice, in order to
ensure consistency across the profession, it is likely that the frequency of recertification will be standardized. However, consideration should be given to the
idea of an earlier recall for doctors whose previous appraisal had identified
weaknesses in their practice. Standards being developed for mutual recognition of CME activity in Europe could also have a bearing on the frequency of
recertification (see below).
Which bodies will be responsible for overseeing the recertification process,
setting the standards and inspecting and enforcing them? CME may be provided by universities, hospitals, specialist societies or local health authorities.
176 Primary care in the driver’s seat
Experiences in Greece and Spain suggest that accreditation of these courses and
activities should be carried out by a single body (UEMS European Advisory
Committee on CME, 2001). Scrivens (2002) makes the distinction between
voluntary professional regulation and mandatory state regulation. State regulations usually set minimum standards, whereas professional bodies set high
standards to which doctors must aspire. Most countries have a central body
responsible for the licensure of all doctors as well as specialist societies which are
responsible for the education and training in particular specialist fields. Recertification in most countries will be the responsibility of the licensing body such as
the General Medical Council in the United Kingdom, whereas the professional
bodies set the standards (e.g. approving CME courses). However, owing to rapid
expansion of the number of CME courses, their capacity to ensure that all activities are of high quality is limited. Other conflicts of interest may arise when
CME is organized by bodies with commercial interests in PC (such as the
pharmaceutical or medical technologies industry).
In the United Kingdom (Box 9.2), purchasing bodies set rules and regulations
regarding the practice of doctors under contract and ask for involvement in
the recertification procedure. The choice of whether recertification applies to all
doctors on the register or only doctors under contract with public insurance
has not been totally clarified. In Germany and Switzerland, participation in
CME is essential for establishing a contractual relationship with the insurance
funds. However, if recertification aims to protect the interests of patients, it
should extend to doctors practicing in the private sector. In fee-for-service countries such as Belgium and France, payments differ according to accreditation.
Inspections in the Netherlands are carried out by three peers – one who has
recently been inspected, one who is due to be inspected and a chairperson
(Swinkels, 1999).
Box 9.2 Recertification in the United Kingdom
The proposals in the United Kingdom give the responsibility to the royal
colleges and specialist societies for providing guidance on what type of
evidence is needed for recertification (Du Boulay, 2000). These organizations are also expected to provide support and retraining for those doctors
who fail to meet the standards. GMC has set out the principles of recertification (General Medical Council, 2001). The Royal College of General
Practitioners has already published guidelines for good practice which
elaborate on these and identify the standards expected of a GP (Royal
College of General Practitioners, 2002). In order to evaluate all doctors on
a regular basis suitable appraisers need to be selected and trained. These
are likely to be peers, thus there are implications of diverting trained
personnel away from front-line care. Lay assessors can be used to assess
dimensions of care other than technical competency (Southgate and
Pringle, 1999) however, doctors are likely to be extremely reluctant to
accept appraisal from anyone other than peers.
Changing professional roles in primary care education 177
In the countries of the former Soviet Union a system of five mandatory
annual attestations (certification) existed for all physicians. Participating in
CME, professional experience, and speciality development were taken into
account. All doctors were divided into three qualifying groups and there were
small salary differences according to their qualification.
Since the establishment of the European Accreditation Council for Continuing Medical Education (EUACCME) in 2000, mutual recognition of CME for the
different specialties (but not for GPs) is possible through the transfer of CME
credits between European countries, between different specialties, between the
European and North American credit systems and in the case of migration of a
specialist within Europe (UEMS European Advisory Committee on CME, 2001).
If free movement of professionals is to be fully realized, then standardized
procedures for recertification have to be agreed upon at the EU level. Even if
standards are devolved to national organizations, some basic principles and
technical aspects would need to be agreed beforehand. Therefore, before CME
and recertification are implemented across the EU, a better understanding of the
possible consequences is necessary. Evaluation of the impact of recertification
(including the comparative advantage of different methods and frequencies of
application) would be beneficial in order to see whether the benefits (measured
in terms of improved quality of PC) are greater than the costs. To date, there is
no specific general practice/family medicine move to mutual recognition of
CME activities in a European context.
Political aspects
Public protection from incompetent practice has traditionally been delegated to
the profession through the establishment of standards of training, qualifications and codes of practice. The decline in public trust and deference has meant
that such structures are no longer deemed to be adequate. Self-regulation in
general has been called into question. In light of this, both governments and
professional bodies have been acting to ensure public confidence is maintained.
Here, the political aspects of the implementation of recertification are briefly
considered.
(a) Legislation. If the state is forced to act through legislation, it may be to
enhance the powers and scope of statutory self-regulatory bodies or to establish
independent bodies to monitor and enforce performance. The introduction of
recertification might require amendments to core legislation concerning the
licensure of medical doctors and would need the support of the national
medical association.
(b) Self-regulation. In order to pre-empt state action, professional bodies in
several countries established their own professional development programmes.
Much of the political controversy around recertification is within the profession
between different specialties vying to control the standards by which they will
be judged. PC doctors need to establish their own standards given the generalist
nature of PC practice compared to hospital-based specialist practice.
(c) Cost of recertification. In order to ensure that recertification is implemented,
the financial responsibility for the cost of recertification must be identified and
178
Primary care in the driver’s seat
budgeted. Direct costs of training and administration are perhaps more obvious
but other economic costs, such as time treating patients or recording activities,
may have a negative impact on service delivery. A supportive environment for
the recertification process will require that managers and health care providers
build ‘protected time for education, training and appraisals’ into service contracts and day-to-day practice. In addition, health care purchasers will have to
recognize the need to invest in education in order to ensure that practice is of
the highest standard (Du Boulay, 2000). Also the funding of appraisals must be
adequate so that resources are not diverted from patient services. The costs of
recertification will not be insignificant and will have to be borne somewhere in
the system, whether by the professionals, the professional bodies or purchasers
(Hayes, 2001). Certainly the costs and benefits of recertification should be
evaluated in order to ensure that a sledge hammer is not being used to crack a
nut, because the prevalence of seriously underperforming doctors is believed to
be low (less than 5%) (Newble, 2001).
(d) Compliance with recertification. In order to ensure that doctors comply with
recertification, the sanctions must be clear. In many countries the assumption
is that the right to practice will be removed. However, in some countries such
as the Netherlands, sanctions are not yet systematically organized and can be
imposed at the discretion of the medical societies (Swinkels, 1999). In the
United Kingdom if underperformance cannot be dealt with locally then a
referral can be made to the GMC, which has the power to remove a doctor from
the register (Southgate and Pringle, 1999). Yet if the aim is to improve health
care delivery, then a doctor failing to meet recertification requirements must
be given support and remedial training. The process must be clearly set out
with appeal processes which would stipulate whether the doctor is suspended
pending further training, at what point they are irrevocably removed from the
register and what criteria might have to be met in order to be reinstated.
The lifelong learning cycle: from continuous medical education to
continuous professional development
Lifelong learning, flexibility and adaptability to new roles and challenges has
been put forward as the new ideal. This is also true for GPs, although to stay in
the mainstream of medical evolutions is very challenging. This is essential,
however, if the claim on the driver’s seat position is to have meaning. The
traditional emphasis on ‘continuous medical education’ has largely proved to
be unsuccessful in changing the competence and daily performance of
attendees. Results from the analysis of a broad range of effect studies on different
methods (Davis et al., 1995) were very clear: traditional lifelong learning
through seminars, retraining weeks and regular reading proves to have almost
no impact on changes in practice performance. These educational tools seem to
bring some new knowledge, but if the acquired knowledge cannot be implemented quickly, it is easily forgotten. Simply recording attendance at CME does
not ensure the fulfilment of the objectives of recertification. It is still possible to
be incompetent in practice (Smith, 2000). Participation in CME may be motivated by other incentives (financial and non-financial) such as meeting friends,
belonging to the group, networking, free holiday, etc. There is a also danger
Changing professional roles in primary care education 179
that recertification provides disincentives for participation in professional
development rather than stimulating it (Buckley, 1999).
In a new joint policy document from the quality assurance board and the
educational board of WONCA Europe (EQUIP and EURACT, 2003), a plea is
made to integrate separate programmes of CME learning and of quality
improvement activities into one process. ‘The emerging requirements of health
care systems focusing on outcome and cost-efficiency combined with new
learning paradigms focusing on knowledge, competence and performance, set
the scene for Continuous Professional Development Planning. This involves
integrating the more traditional options for CME and the more occasional initiatives on Quality Development.’ Basic principles are: patient and community
priorities concerning health care should be central; CPD should be based on the
learners’ daily working practices; goals should be set by the GP and/or the practice; and integration should be a continuing process and not a series of sporadic
efforts. Central instruments are the personal development plan and the learning
portfolio. It should be based on adult learning principles. During the process
data should be collected and performances analysed utilizing evidence-based
guidelines. To make it a continuous process, practice enabling and reinforcing
strategies should be optimized.
The “good CPD guide” (Grant and Chambers, 1999), published by the Joint
Centre for Education in Medicine, tries to make CPD an instrument at the structural organization level, clearly managed at trust, PC group or practice level, in
pursuit of increased quality of patient care and of service development. Personal
Development Plans (PDPs) have to start from individual needs, but should be
put in a practice or service context for reinforcement and dissemination and
should be discussed with colleagues to form part of the business plan of the
clinical unit which makes them open to scrutiny and able to be monitored.
These plans should reflect personal interest but should also encompass corporate needs. Practices or PC groups should have a clear written CPD policy and a
projected time available, bearing in mind that management of resources is also
about better targeting and ensuring value for money. An education-oriented
culture should be supported, with a focus on audit, clinical effectiveness and
research.
At national government level, a central role in the CPD process should come
from recertification bodies and procedures. Traditional CME has a reaccreditation system based on credits that are collectively acquired in seminars or meetings. Their primary goal is that physicians gain professional knowledge. If the
focus shifts to competence and performance, the recertification process should
be adapted to the new paradigm. This would require a fundamental change
from counting credits and monitoring attendance to evaluating personal development plans and monitoring involvement in a quality control process. This
would entail expanding the field of accreditation by incorporating a new set of
instruments in order to discover what the learning needs are and how they can
be met. It is clear that a flexible system of accreditation is important, which
would include recertification (competency evaluation) and both practical
and professional accreditation (performance evaluation) in a supportive and
transparent manner that is overseen by the appropriate national authorities.
At present CPD is more a concept than a reality. Table 9.5 shows the countries
180 Primary care in the driver’s seat
Table 9.5 Features of CME and CPD in Europe
Austria
Belgium
Bosnia and
Herzegovina
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Israel
Italy
Lithuania
the Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
United Kingdom
Compulsory
Responsible
body*
Include
portfolio/
learning
plan
Feedback
procedures
Official
guidelines
N
Y
N
P
G
P
N
N
N
Y
Y
N
Y
Y
N
Y
N
Y
N
Y
N
N
Y
N
Y
Y
Y
Y
Y
N
N
Y
Y
N
N
N
N
N
N
P
P+S
P+G
n.a.
P
P
P
U
S
U
P+S
S+U
P
G
n.a.
n.a.
P+G+U
U
P+S
n.a.
G
P
P+U+S
n.a.
Y
Y
N
N
N
N
N
Y
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
n.a.
N
N
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
n.a.
N
N
Y
Note: *Government (G), Profession (P), Scientific societies (S) or Universities (U); n.a. = not available.
Source: EURACT (2004).
that have not adopted new accreditation systems as a whole, but that increasingly include elements like peer review and other feedback procedures within
official guidelines. Individual portfolios that are already utilized in the new
curricula for basic medical education and specialty training are still rarely used
in continuing medical education.
Conclusions
Globally the specialist-centred care model is predominant in medical universities. In some countries, however, there is more input from GP departments,
bringing the community perspective into the curriculum. In terms of the widely
accepted specialty training, family medicine as a profession, at least in its
documents and position papers, is aware of the changing needs of society, the
Changing professional roles in primary care education 181
new emphasis on patient empowerment, and on population-based prevention
and screening. Equal access, cooperation and community orientation now serve
as the basic cornerstones of the discipline in Europe. To date, what remains
unclear is the impact of these principles on the actual content of teaching and
training.
In recent decades, general practice has gained a more central position in most
European health care systems, owing to its strong position as the first line of care
as well as its emergence as a scientific discipline and as a specialization in academic research. National and international organizations of GPs have played a
leading role in achieving this, as has the corresponding financial support and
other resources dedicated to promoting general practice. Increasingly, official
procedures for accreditation and reaccreditation are being introduced as quality
guarantees that will further strengthen PC physicians as professionals. The realization of this goal will also require a number of political factors: changes in
legislation, delegation of implementation to self-regulating bodies, estimation
of the direct and indirect costs of recertification, designation of penalties and
sanctions to be imposed for non-compliance, clear allocation of responsibilities
for funding and implementation, and adoption of common EU standards. The
methods adopted should also be easily incorporated into doctors’ daily work
and cause minimal disruption to service delivery. To bring continuous education in better balance with the competence and performance in daily practice, a
new emphasis is needed on Continuous Professional Development Planning as
the content and control system for the future. At present this is still mainly a
topic for publications and seminars, as it has not yet been integrated into the
field of daily practice. Yet, as an ideal to strive for it seems quite promising.
The academic and professional groups in the ‘forefront’ countries of general
practice development will need to ensure continuous adaptation to new professional and patient needs. Countries that were ‘late adopters’ will be faced with
the enormous task of changing practice, training and teaching all at the same
time. Small, incremental change is the only realistic way to implement changes
of this scope in these countries. Accreditation and recertification mechanisms
will be essential in order to ensure recognition of general practice as a specialty.
Inertia, resistance from the specialists and other ‘competing’ PC providers such
as paediatricians should also not be underestimated. Implementing changes will
require appropriate human and financial resources. The newly founded professional associations of general practitioners and the wide social support of measures that seek to better meet the needs of the community can serve as an engine
of reform in countries with health care systems in transition. Strengthening the
position of the professional bodies of GPs is thus crucial for the sustainability of
PC-driven health care reforms.
References
Barr, D.A. and Schmid, R. (1996). Medical education in the former Soviet Union, Academic
Medicine 71: 141–145.
Boelen, C. (1999). Adapting health care institutions and medical schools to societies’
needs, Academic Medicine 74(8): S11–S20.
182 Primary care in the driver’s seat
Boerma, W.G.W. and Fleming, D.M. (1998). The Role of General Practice in Primary Health
Care. Copenhagen: WHO Regional Office for Europe.
Buckley, G. (1999). Revalidation is the answer, British Medical Journal 319 (7218):
1145–1146.
Davis, D.A., Thomson, M.A., Oxman, A.D. et al. (1995). Changing physician performance.
A systematic review of the effect of continuing medical education strategies, Journal of
the American Medical Association 274(9): 700–705.
Du Boulay, C. (2000). Revalidation for doctors in the United Kingdom: the end or the
beginning? British Medical Journal 320(7248): 1490.
EQUIP and EURACT (2003). Continuing professional development in primary health
care: Quality development integrated with continuing medical education (http://
www.equip.ch/groups/cme/rep/CME_QD.pdf, accessed 3 March 2004).
EURACT (1999). Position on Specific Training of General Practitioners in Europe. Leuven:
European Academy of Teachers in General Practice (EURACT).
EURACT (2004). EURACT Statement on Selection of Trainers and Teaching Practices for Specific
Training in General Practice. Tartu: European Academy of Teachers in General Practice
(EURACT).
Firth-Cozens, J. and Greenhalgh, J. (1997). Doctors’ perceptions of the links between stress
and lowered clinical care, Social Science and Medicine 44(7): 1017–1022.
Flexner, A. (1910). Medical education in the United States and Canada. A report to the
Carnegie Foundation for the advancement of teaching. Boston: Carnegie Foundation
for the Advancement of Teaching, Bulletin 4.
General Medical Council (2001). Good Medical Practice. London: General Medical Council
(http://www.gmc-uk.org/standards/good.htm, accessed 3 March 2004).
Gossop, M., Stephens, S., Stewart, D. et al. (2001). Health care professionals referred for
treatment of alcohol and drug problems, Alcohol and Alcoholism 36(2): 160–164.
Grant, J. and Chambers, E. (1999). The Good CPD Guide: A Practical Guide to Managed CPD.
London: Joint Centre for Education in Medicine.
Grundmeijer, H. and Rutten, G. (eds) (1996). Leerdoelen in de huisartsgeneeskunde
[Educational objectives in GP health care]. Utrecht: De Tijdstroom.
Harden, R.M., Crosby, J.R., Davis, M.H. and Friedman, M. (1999). AMEE Guide No. 14:
Outcome-based education: Part 5 – From competency to meta-competency: a model
for the specification of learning outcomes, Medical Teacher 21(6): 546–552.
Hayes, S. (2001). GMC’s proposals for revalidation. Appraisal is helpful only if done well,
British Medical Journal 322(7282): 358.
Heyrman, J. (2004). Educational Agenda. Leuven: European Academy of Teachers in
General Practice EURACT.
Jolly, B., McAvoy, P. and Southgate, L. (2001). GMC’s proposals for revalidation. Effective
revalidation system looks at how doctors practise and quality of patients’ experience,
British Medical Journal 322(7282): 358–359.
Ko Ko, U. (1994). Education for medical practice for tomorrow, Medical Education 28:
54–61.
Kuznethova, O.U., Yaremenko, L.N. and Frolova, E.V. (2000). Postgraduate education of
family physicians in Saint-Petersburg – History, development and perspectives,
Russian Family Doctor 1: 13–17.
Leeuwenhorst Group (1974). The General Practitioner in Europe. A Statement by the Working
Party appointed by the Second European Conference on the Teaching of General Practice.
Dublin: Leeuwenhorst Group.
Leeuwenhorst Group (1977). The Contribution of the General Practitioner to Undergraduate
Medical Education. Statement by the Leeuwenhorst Group. Dublin: Leeuwenhorst
Group.
Lember, M. (1996). Family practice training in Estonia, Family Medicine 28: 282–286.
Changing professional roles in primary care education 183
Lember, M. (2002). A policy of introducing a new contract and funding system of general
practice in Estonia, International Journal of Health Planning and Management 17: 41–53.
New Leeuwenhorst Group (1981). A description of the work of a general practitioner. A revised
statement by the Leeuwenhorst Working Group. Dublin: New Leeuwenhorst Group,
November 1981 (http://euract.org/html/doc003.shtml, accessed 3 March 2004).
Newble, D. (2001). GMC’s proposals for revalidation. Purpose of revalidation process must
be agreed on, British Medical Journal 322(7282): 358.
Norcini, J.J. (1999). Recertification in the United States, British Medical Journal 319(7218):
1183–1185.
Royal College of General Practitioners (2002). Good Medical Practice for General Practitioners. London: Royal College of General Practitioners.
Rusovich, V., Boerma, W.G.W. and Schellevis, F. (2000). Going ahead with the primary
care in Belarus, Pilot project in Minsk region, Medizina (Belarussian) 1: 15–17.
Schepin, O.P., Dmitrieva, N.V. and Korotkih, R.V. (1996). Theoretical and organizational
aspects of primary health care in Russia, Problemy Sotsialnoi Gigieny Istoriia Meditsiny 2:
3–7.
Scrivens, E. (2002). Accreditation and the regulation of quality in health services. Regulating entrepreneurial behaviour in European health care systems, in Saltman, R.B.
Busse R. and Mossialos, E. Regulating Entrepreneurial Behaviour in European Health Care
Systems. Buckingham: Open University Press.
Shabrov, A.V., Dosenko, M.S. and Yubrina, I.V. (2001). Family medicine tutors training as a
component of educational process in general practice, Russian Family Doctor 4: 56.
Smith, R. (2000). Should GMC leaders be put to the sword? No, doctors must work
together, British Medical Journal 321(7253): 61.
Southgate, L. and Pringle, M. (1999). Revalidation in the United Kingdom: general principles based on experience in general practice, British Medical Journal 319(7218):
1180–1183.
Starfield, B. (1998). Primary Care: Balancing Health Needs, Services and Technology. Oxford:
Oxford University Press.
Swinkels, J.A. (1999). Reregistration of medical specialists in the Netherlands, British
Medical Journal 319(7218): 1191–1192.
UEMO (1995). Consensus Document on Specific Training for General Practice. European Union
of General Practitioners Reference Book 1995/96, 65–69. Stockholm: European Union of
General Practitioners (UEMO).
UEMS European Advisory Committee on CME (2001). Update on Structure of National CME.
Brussels: European Union of Medical Specialists (UEMS). (http://www.uems.be/
eaccme.htm, accessed 20 May 2002).
Vuori, H. (1979). Lääketieteen historia [Medical history]. Jyväskylä: Gummerus.
Weir, E. (2000). Substance abuse among physicians, Canadian Medical Association Journal
162(12): 1730.
WHO (1998). Framework for Professional and Administrative Development of General Practice/
Family Medicine in Europe. Copenhagen: WHO Regional Office for Europe.
WONCA Europe (2002). The European Definition of General Practice/Family Medicine 2002.
Singapore: World Organization of Family Doctors (WONCA) (http://euract.org/html/
page03a.shtml, accessed 3 March 2004).
WONCA/WHO (2002). Improving Health Systems: The Contribution of Family Medicine – A
Guidebook 2002. Singapore: World Organization of Family Doctors (WONCA).
chapter
ten
Managing primary care
behaviour through
payment systems and
financial incentives
Stefan Greß, Diana M. J. Delnoij and
Peter P. Groenewegen
Introduction
This chapter assesses the influence of payment systems and financial incentives
on primary care doctors. This is a broad topic and not a new one. There is a
veritable mountain of theoretical and empirical literature on the influence of
payment systems on physician behaviour generally. Moreover, it is also clear
that the actual impact of payment systems and their incentives are greatly
dependent on health system context as well as other (non-financial) incentives.
Although the literature on payment systems for physicians in general and GPs
in particular has been very helpful in writing this chapter, it also has a drawback:
the emphasis is on the pure effects of payment systems. However, we should
be aware that payment systems only work within and in interaction with a
broader institutional context. Specific elements of health care institutions that
work well in their original institutional context turn out to be useless when
transferred to other health care systems. Also, the stability of institutional
arrangements influences whether or not certain elements work.
Payment systems and financial incentives are important but other incentives
are also relevant. One of our arguments in this chapter is that the incentives of
payment systems probably get too much attention, not because they are the
most important in steering the behaviour of health care professionals, but
because they can be more easily manipulated than other incentives.1
The main focus of this chapter is to describe the (potential and real world)
Managing primary care behaviour through payment systems 185
effects of payment systems and financial incentives on the behaviour of primary
care doctors. In order to answer this research question we first analyse the
intended effects of payment systems and financial incentives (section two).
However, actual effects depend not only on the behaviour and value systems of
physicians but also on context-based incentives which counteract those
embedded in the payment system. Therefore, the next step is to analyse the
potential interaction of health system context and payment systems (section
three). In section four we describe the effects of payment systems and financial
incentives on providers, patients and society on the basis of empirical studies of
(changes in) payment systems (in other words: we describe the real effects). In
the final section we draw some policy conclusions from our findings.
Our analysis is based on an extensive literature review which has been conducted in spring and summer of 2002. Where appropriate, we illustrate our
findings with country examples.
Intended effects of payment systems and financial incentives
We focus on the most common payment systems and their intended effects.
Each system can be distinguished by the type of unit which is being paid for.
In fee-for-service systems payment is made for units of service. In theory physicians and patients could negotiate the price for individual services at each point
of contact. In fact fee-for-service systems are usually based on fee schedules
which classify physicians’ activities with varying degrees of precision.
Physician income in fee-for-service systems is determined by the number of
services multiplied by the price of services. In general, fee-for-service is intended
to allow physicians to react in a flexible manner to patients’ needs and also
grants them a high degree of autonomy. However, interventions by health
authorities or health insurers aimed at containing costs or shifting relative
prices of services are likely to have direct effects on clinical decision-making
(Groenewegen and Calnan, 1995). Financial rewards are directly connected
with work performed. Fee-for-service systems still are widespread in Europe and
quite popular with the medical profession. Table 10.1 shows that only some
countries rely entirely on fee-for-service (for example Belgium, France and
Luxemburg). In other countries physicians are paid fee-for-service for groups of
patients (for example, patients with social health insurance in Germany and
patients with private health insurance in the Netherlands).
In capitation-based systems payment is made for individual patients. The provider is paid a specified sum of money for the care of individual patients for a
specified period of time. Patients usually have to register with individual physicians or groups of physicians. Payment is independent of the extent of services
individual patients require. Ideally payments to physicians are risk-adjusted for
differences in morbidity of patients in order to reduce incentives for risk selection. In fact payments mostly vary according to the age of patients but are
usually not so fine-grained as to reflect differences in service utilization. In some
countries there are also payments for patients who live in deprivation areas (see
Box 10.2). Physician income is determined by (risk-adjusted) capitation multiplied by individual patients enrolled with the physician. There may be limits
186 Primary care in the driver’s seat?
as to the maximum number of patients enrolled with one physician and/or
degressive capitation payments above a threshold of patients. Capitation is
intended to ensure access to primary health care services for every registered
patient. Furthermore, incentives for supplier-induced demand are reduced
and incentives for continuity of care are increased. In European primary care
capitation-based systems are not as common as fee-for-service systems (see Table
10.1). Mostly, the capitation payment is combined with some fee-for-service
payments.
In salary systems the physician is paid for units of time. Remuneration is
independent of the volume of services and independent of the number of
patients. Salaried providers work within a defined schedule; in some countries
they are allowed to treat patients privately after hours. Physician income is
determined by the content of the employment contract. Salaries mostly depend
on the physician’s qualification and his or her task profiles and provide a high
degree of income security to physicians. Salary systems are still predominant in
the transitional countries in central and eastern Europe although they are
increasingly being replaced by other payment systems. A salaried payment system is intended to combine basic income security for physicians with high
accessibility for patients. Salaried payment in eastern Europe is substituted by
capitation and fee-for-service. However, salaries are still widespread in Portugal,
Scandinavia, and Spain (see Table 10.1).
While fee-for-service, capitation and salary are the three basic payment systems for GPs, there are several varieties of each. One of the most interesting
varieties is integrated capitation. Integrated capitation systems combine a capitation payment for services delivered by different providers or at different levels of
care. In contrast to simple capitation other expenditures such as prescription
drugs, specialist services or even services in secondary care can be incorporated
in integrated capitation payments. GPs may even act as fundholders by purchasing hospital care for their patients.2 Thus, physician income is determined by
integrated capitation payments multiplied by registered patients minus payments to other providers or to other levels of care. Integrated capitation is
intended to provide even better incentives for continuity and comprehensiveness of care. At the same time it requires well developed mechanisms for the
allocation and monitoring of capitation payments. So far integrated capitation
systems have not been very successful in Europe.
Mixed payment systems come in three varieties. The first is that GPs are paid
according to a mixed system for all their patients, mostly consisting of a basic
payment (salary or capitation) and additional payments to provide incentives
for certain tasks. Target payments are used to provide incentives to reach predefined levels of services, such as parts of the population taking part in screening
programmes. Function payments are used to reward physicians for services not
included in their basic contract, such as providing out-of-hours emergency services. Here the payment system is mixed at the level of patients (for examples
see Box 10.1). The second variety is that GPs get paid according to a different
system for different patient groups, e.g. according to insurance status. Here, the
system is mixed at the level of GPs (for an example see Box 10.2). The third
variety of mixed payment system is that some GPs are salaried and others paid
fee-for-service or capitation. Here, the mix is at health care system level. Espe-
Managing primary care behaviour through payment systems 187
Box 10.1 Mixed payment systems at the level of patients
Throughout several reforms the payment system for GPs under the NHS in
the United Kingdom has maintained the principle of capitation payment
that had been used since long before 1948. Today, the payment system of
GPs in the United Kingdom consists of a complicated mix of allowances,
capitation payment, target payments, and fees-for-services (Department
of Health, 2002). As a result of the introduction of target payments for
preventive activities there has been a remarkable growth in the number of
nurses working in general practices. These practice nurses take up health
promotion, along with a whole range of other tasks, for example in the
field of care for the chronically ill (Atkin et al., 1994; Hibble, 1995).
Very recently the Italian Government has reformed the payment system
of GPs in the NHS. GPs in Italy are self-employed and receive a capitation
payment, with a maximum of 1,500 patients per GP. The capitation now
has a variable part (30%) and a fixed part (70%). The variable component
is defined by individual Health Authorities (HAs) which first have to
define priorities which can then be linked to GP performance via the variable component of the capitation payment. A recent study found that so
far 61 health authorities (of 196 health authorities in Italy 162 replied to a
questionnaire) have defined targets for the variable component. Targets
are mostly related to costs for drugs (42 HAs), costs for hospital admissions
(31 HAs) and costs on diagnostic and lab tests (13 HAs).3 So far there is
no information on the outcome of these performance-based payments
(Vendramini, 2002). However, we know from experience of other countries that health care expenditure can decrease when primary care providers have incentives to curb costs for drugs or hospital admissions
(Wilton and Smith, 2002).
cially in the second and third variety, GPs may not show the behavioural effects
of the pure payment systems; in the second variety because there may be forces
against differential treatment of different patients by the same GPs; in the third
variety because one group of GPs may be the dominant one, setting the norms
for the other group. The incentives of salaried service with regard to working
hours, for example, work out differently in a system with predominantly
salaried GPs or in a system with predominantly fee-for-service GPs.
Table 10.1 provides an overview of GP payment systems as of 2004 in the
15 countries of the European Union and five pre-accession countries. From
Table 10.1 it is clear that most countries have a mixed system, and that in more
than half of these cases the payment is mixed at the level of patients or GPs. This
implies that GPs in those countries are not exposed to “pure” incentives.
There has been a clear trend in Europe towards mixed payment systems. In
theory mixed payment systems (at GP level) can combine the advantages of
several payment systems and avoid their disadvantages. However, even in
United States Managed Care organizations, most payment systems are relatively
188 Primary care in the driver’s seat?
Box 10.2
Mixed payment systems at the level of GPs
Financial incentives and payment systems in German primary care differ
quite significantly depending on the insurance status of patients. All primary care physicians in Germany have a mix of privately and socially
insured patients. Physicians receive fee-for-service payments for both privately and socially insured patients. However, there are different fee
schedules for each type of patient. Providers are allowed to charge much
higher fees for privately insured patients than for socially insured patients.
The difference may be even larger if patient and physician agree to refrain
from applying the (private) fee schedule. The fee schedule for patients
with private health insurance is partly based on the fee schedule for
patients with social health insurance. However, since private health
insurers do not have any contractual relations with primary care physicians, this fee schedule is issued by ordinance by the Federal Government
while the fee schedule for socially insured patient is jointly determined by
peak organizations of providers and sickness funds. Since there is no
budget for services which are provided to privately insured patients, physicians try to compensate for stagnating or even decreasing income from
sickness fund patients by treating privately insured patients. As a consequence, preferential treatment of these patients is quite common and
health care expenditures of private health insurers for ambulatory care are
skyrocketing.
simple in order to ensure low administrative costs and high transparency. These
limits of payment systems underscore the importance of non-financial methods
of motivating physicians – such as screening and selection, explicit prescription
of desired performance and monitoring of compliance (Robinson, 2001).
Interaction of payment systems and financial incentives with
health system context
In general, it is very difficult to separate the analysis of financial incentives from
the general context of the health care (financing) system. Thus, experiments
made with financial incentives in one country and the results obtained may not
be reproduced straightforwardly in another country unless major structural
reforms are undertaken. It must also be kept in mind that other non-financial
incentives such as mandatory practice guidelines affect physician behaviour
and possibly income (Chaix-Couturier et al., 2000). Specifically, payment systems set financial incentives for the behaviour of physicians. However, the
method of payment is only one factor determining the outcome of primary care
for patients. Therefore, it is difficult to determine whether the behaviour of
primary care providers correlates with particular payment methods. Additionally, it would be impossible to reform payment methods without taking into
Managing primary care behaviour through payment systems 189
Table 10.1 GP payment systems as of 2004 in 15 EU Member States and selected
accession states
Country
Payment system
Remarks
Austria
Mixed at patient
level
Voucher system, which ties patients to one GP
for a 3-month period. Payment consists of a flat
rate per 3-month period (regardless of the
number of services required) plus fee-for-service
(Hofmarcher and Rack, 2001).
Belgium
Fee-for-service
(Kerr, 2000)
Denmark
Mixed at patient
level
Capitation (about one third of their income)
and additional fee-for-service (Vallgarda et al.,
2001).
Finland
Mixed at health
system level
In “regular” health centres (the previously
dominant system): salary, sometimes with
bonuses, plus extra payments for certificates of
health.
In “personal doctor” centres (now covering
about 55% of the population): salary (60%),
capitation (20%), fee-for-service (15%), local
allowances (5%) (Järvelin 2002).
France
Fee-for-service
(source: authors)
Germany
Fee-for-service
Fee-for-service according to a Uniform Value
Scale (EBM) which ties the reimbursable
“points” to the global budget negotiated with
the sickness funds (Busse, 2000b).
Greece
Salary
In addition to their salaries, many doctors
receive fee-for-service from private practice
(Tragakes and Polyzos, 1996).
Ireland
Mixed at GP level
Patients under GMS (General Medical Services;
about 30% of the population) are listed with a
GP who receives an age/gender dependent
capitation fee. The rest of the population is
privately insured under Voluntary Health
Insurance and pay fee-for-service, after which
they are (partly) reimbursed (source: authors).
Italy
Mixed at patient
level
Capitation plus fees for specific services and
rewards for effective cost containment
(Donatini et al., 2001).
Luxembourg
Fee-for-service
(Kerr 1999)
the Netherlands
Mixed at GP level
Capitation for publicly insured patients (61%)
and fee-for-service for privately insured
patients (39%). (source: authors).
Portugal
Mixed at GP and
health system level
Payment systems: Public sector → salary (plus
private – fee-for-service – practice for 50% of
GPs).
Independent contractors → fee-for-service
(Dixon 1999).
190 Primary care in the driver’s seat?
Table 10.1 Continued
Country
Payment system
Remarks
Spain
Mixed at health
system level
“Traditional” model (independent, singlehanded GP) → capitation.
“Primary Care Teams” (dominant model;
health centres) → salary (Rico, 2000).
Sweden
Mixed at health
system level
In public health centres (86% of GPs) → Salary
+ fee per patient (Hjortsberg and Ghatnekar
2001).
GPs working as private contractors (but paid
via taxes as well) are paid through capitation
(40–70% of income) and a smaller fee per
patient consultation.
United Kingdom
Mixed at patient
level
Payment consists of capitation (50% of the
income), allowances, fee-for-service and
performance related payment (Robinson,
1999).
Czech Republic
Mixed at patient
level
Reimbursement consists mainly of capitation
plus fee-for-service (about 30% of income) for
“desirable” services (Busse, 2000a).
Hungary
Mixed at health
system level
GPs have four employment options. The
majority (77%) work on a contract basis with
local government and receive a capitation fee;
21% work in salaried employment of local
government; 3% are independent contractors
with the Health Insurance Fund, under
capitation payment; and a few GPs are
employed by hospitals. (Gaál et al., 1999)
Poland
Capitation
(Karski and Andrzej, 1999).
Slovakia
Mixed at patient
level
Payment consists of a capitation fee (60% of
income) and fee-for-service (40%) (Hlavacka
and Skackova, 2000).
Slovenia
Mixed at health
system
Primary care doctors work in salaried
employment or as private practitioners paid on
a fee-for-service basis (Albreht et al., 2002).
Accession
countries
account the health system context in primary care (De Maeseneer et al., 1999).
Basically, in primary care the most important factors of health system context
consist of the way financial access to health services is organized (benefits-inkind versus benefits-in-cash; formal and informal user charges versus free
access), the process of referral to secondary and tertiary care (extent of the gatekeeping role for primary care providers) and the allocation mechanism of
Managing primary care behaviour through payment systems 191
patients towards providers of primary care (fixed patient lists versus free choice
of providers for patients).4
Fee-for-service payments financed by private health insurers are usually combined with benefits-in-cash and reimbursement for privately insured patients.5
In tax-financed or contribution-based systems the extent of user charges is
smaller and benefits are granted either in cash or in kind. However, in health
care systems with fee-for-service payment there is no gatekeeping role for
primary care providers. Also, patients usually have free choice of providers and
are not on a fixed list of primary care providers. As a consequence, the position
of GPs as the doctor of first contact with the health care system providing
continuous, comprehensive and coordinated care is quite weak. Furthermore,
access for patients is hindered by user charges and by reimbursement
mechanisms.
Capitation payments are usually funded through taxation or social health
insurance contributions and not through private health insurance premiums.
User charges and benefits-in-cash are much less common than in fee-for-service
payment systems. Capitation implies fixed lists of patients and thus limited
choice of providers for the patient; a choice that is restricted further by the fact
that GPs under capitation payment are also usually gatekeepers to specialized
care. As a consequence GPs have a strong position as providers of primary
health care by evaluating patients’ needs or urgency for access to secondary or
tertiary care. Access may be hindered by risk selection strategies due to nonrisk-adjusted capitation payments. Furthermore, under capitation payment
physicians may feel encouraged to provide preventive services, since they
reduce future costs (Boyden and Carter, 2000; Gosden et al., 2001). And because
GPs under capitation payment have fixed patient lists, they are theoretically
in an excellent position to provide services that are targeted towards the
population.
The most complex payment system with regard to health system context
is integrated capitation. On a significant scale it was found in Europe only
in the United Kingdom’s fundholding scheme. At least in theory it can also
be applied in social health insurance systems. GPs have considerable incentives
to reduce patient access to secondary and tertiary care, which in turn increases
incentives for risk selection inherent in simple capitation payments. On
the other hand, integrated capitation on the basis of risk-adjusted capitation
payments greatly increases incentives for interdisciplinary coordination
of care through active disease management beyond the boundaries of primary
care.
Salary payments for GPs are usually funded through taxation and less
frequently through contributions. Mostly patients are not registered with
individual GPs but are required to receive their primary health care at specific
health centres or polyclinics. The attending physician may differ from contact
to contact. Formally there are low or no user charges but in several transitional
countries informal user charges (‘envelope money’) are still quite common. Furthermore, the low level of remuneration in these countries increases the incentives for the development of parallel systems of private care (100% user charges).
This in turn can undermine the functioning of the official salaried system even
further.
192 Primary care in the driver’s seat?
Figure 10.1 Incentives of payment systems and of the health system context for central
values of primary care.
Payment System
Fee-for- service
(Integrated)
Capitation
Salary
Health System Context
User
charges,
benefits
in cash
Yes
No
No
Incentives for central values of primary care
First
contact
Accessibility
Continuity
Comprehensiveness
Coordination
No
Gatekeeping
function
of GPs
No
0
−
−
−
−
Yes
No
Yes
No
+
0
+1
+2
+
−
+
+
+
0
Fixed
patient
lists
Notes: + positive incentives, − negative incentives, 0 neutral.
1
Negative incentives in case of non-risk-adjusted capitation payments.
2
Negative incentives in case of (informal) user charges.
Source: partly adapted from De Maeseneer et al. (1999).
Figure 10.1 summarizes the incentives of fee-for-service, capitation, integrated capitation and salary based on their intended effects, health system context and central values of primary care as described by Starfield (1996) and
Boerma and Fleming (1998):
• primary care should be the first point of contact for people with (new) health
•
•
•
problems.
primary care should be continuous and comprehensive.
primary care should be the co-ordinator of care in other parts of the health
care system.
primary care should be accessible to patients, irrespective of their age, gender
or illness, and to other health care providers.
Real world effects of payment systems and financial
incentives
Impact on provider behaviour
First of all, it should be noted that most of the available literature focuses on
the intended effects and economic incentives of payment systems. Furthermore, most empirical studies on the actual effects of payment systems do not
satisfy high methodological standards and criteria (De Maeseneer et al., 1999;
Chaix-Couturier et al., 2000). Those that do fulfil these criteria find effects that
are smaller quantitatively than may be expected (Gosden et al., 2001).
But, all in all, the available evidence clearly states that payment systems do
influence physician behaviour (Gosden et al., 2004). However, from an economic point of view, physicians do not only try to maximize income and minimize their workload. Their utility function also consists of other non-price
elements such as ethical restraints, professional standards which may dilute or
even completely remove incentives for physicians to provide ineffective care
merely to increase their income and thus limit supplier-induced demand.6 Thus,
Managing primary care behaviour through payment systems 193
payment systems do not always have the same effects on physician behaviour
(Jegers et al., 2002). However, two trends can be deduced from available studies
(De Maeseneer et al., 1999; Chaix-Couturier et al., 2000; Gosden et al., 2001;
Gosden et al., 2004).
The first trend is that under fee-for-service payment systems doctors tend to
delegate fewer tasks to other health care providers than under (integrated) capitation or salary payment systems. This is not surprising since fee-for-service
payment systems contain incentives to maximize income by maximizing selfproduced services which of course also entails longer working hours.7 Health
authorities or health insurers try to counteract the trend for the expansion of
services under fee-for-service systems by setting (negotiated) budgets for primary care services. They also try to steer provider behaviour by changing relative prices for services, for example by reducing relative prices for technical
procedures and by raising relative prices for time-consuming individual counselling. While fee-for-service payment systems increase activity of physicians,
they also allow for a high degree of flexibility (Engström et al., 2001). Fee-forservice systems are more open to fraud than other payment systems, since GPs
can claim for services they have not provided. Although fraud certainly runs
contrary to professional standards it is not unheard of in fee-for-service
systems.
The second trend is closely related to the first one. While there may be
“underdelegation” in fee-for-service systems there may be “over-delegation” in
salary and capitation systems. In capitation in fact there are incentives to
encourage physicians to withhold care, resulting in undertreatment for
patients. GPs can reduce their workload without reducing their income by referring their patients to other providers and can increase income by increasing the
number of patients on their lists (Lynch, 1998). Salaried physicians are able to
use free time to treat private patients in order to augment their income and
physicians under capitation can maximize income by increasing the number of
patients on their patient list. For physicians in capitation systems with badly
risk-adjusted payments it is profitable to attract favourable risks (health care
costs for the individual are lower than captitation payments for the individual)
and actively to discourage non-favourable risks (health care costs for the individual are higher than capitation payments for the individual). However, this
kind of behaviour is severely restricted by ethical restraints and so far there is
little evidence of it in Europe (Lynch, 1998). While risk-adjusted capitation
payments are technically and administratively complex, they greatly reduce
incentives for risk selection in situations where ethical restraints against risk
selection may be less effective (Hutchinson et al., 2000).
Impact on access and patient satisfaction
In fee-for-service systems the combination of free choice of providers and
the trend towards underdelegation both contribute to the fact that patients
consume more services than in capitation or salary payment systems. Patients
often visit several GPs in the course of the same illness and GPs may apply
different diagnostic and therapeutic procedures. Non-compatible therapeutic
194
Primary care in the driver’s seat?
procedures (e.g. different medication resulting in a dangerous combination of
drugs) may endanger the health of the patient. However, without evidence on
patient health status and clinical outcomes it is unclear if the increased consumption of services itself is hazardous or beneficial for patients (Gosden et al.,
2001).
Capitation payment systems provide a higher degree of coordinated care for
the patient (Engström et al., 2001). Since they have to enrol with a specific GP
and GPs usually coordinate other levels of care, information on the patient
needs is much less fragmented than in fee-for-service systems. Of course, owing
to fixed patient lists and the gatekeeping function of the GP, free choice of
providers is restricted. However, usually patients are free to enrol with another
GP after a specified period of time. While this mechanism increases choice
options for the patients, it opens up opportunities for risk selection by GPs in
(integrated) capitation systems. Although this behaviour is quite uncommon in
Europe, there are incentives for GPs to force unfavourable risks to look for other
physicians. This behaviour would eradicate the advantages of capitation systems with regard to continuous and coordinated primary care for the group of
patients needing it the most.
In salaried systems patients often complain about discourteous physicians.
This behaviour probably reflects low motivation of providers who have very
limited opportunities to increase income.8 Moreover, private practice may not
only financially but also professionally be more rewarding. Especially in underfunded health care systems in central and eastern European countries patients
have to resort to informal co-payments in order to obtain the attention and the
resources of the physician.9
Of course these often substantial user charges disadvantage patients with
lower income who may not be able to pay additional money for ostensibly free
services. Thus, the two central functions of salaried payment – income security
for physicians and free access for patients – are often not realized in underfunded health care systems with salaried physicians in primary care.
Impact on costs
Policy-makers believe that payment systems are crucial for reaching general
health policy objectives at a system level – such as increasing efficiency,
responsiveness and equity of health care but also for reaching cost containment
objectives. However, not every payment system is suitable for reaching all
objectives at the same time.
In theory, price and volume of services in fee-for-service systems are openended. Therefore, fee schedules and budgets are supposed to influence the mix
of services as well as price and volume. Transaction costs are high for negotiating fee schedules, monitoring for fraud, controlling budgets and of course for
settling individual bills of individual providers – either directly with the patient
(benefits-in-cash) or with health authorities or health insurers (benefits-inkind). Fee-for-service systems may still be preferred to other payment systems
due to a high degree of choice for patients. However, this choice option creates
higher health care costs due to less coordinated and less integrated care. These
Managing primary care behaviour through payment systems 195
costs are financed by user charges for patients and/or through higher taxes,
contributions or premiums.10
Transaction costs of capitation payment systems are lower than those of feefor-services systems since payment is based on individual patients – which is
simple to calculate – and not on individual services. Regulation costs especially
of integrated capitation may be high due to the necessity of the development
and refinement of risk adjustment formulas. However, capitation systems tend
to have a containing effect on health care costs (Delnoij et al., 2000) and provide
a stable financial environment for physicians while at the same time there is less
choice for patients.
Salaried payment systems have very low transaction costs since physicians
receive predetermined payments for units of time according to their qualification and tasks. Furthermore, these payments are easy to account for in a budgetary sense – which may be the reason why they are frequent in tax-financed
systems. However, societal costs of underfunded salaries can be quite substantial. If physicians feel they have to augment their income by treating private
patients and/or raising informal user charges of patients’s trust in the system is
eroded. However, it is important to note that this erosion of trust may not be
caused by a specific payment system (in this case salaries) but by the underfunding of the health care system. Obviously, policy-makers tend to prefer salaries if
they want to keep tight or even underfunded budgets – precisely because salaries
are easy to administrate and to control.
Policy conclusions
Payment systems and financial incentives do influence the behaviour of primary
care providers. However, how exactly and to what extent depends on a number
of other influences such as ethical and professional constraints and health system context. Thus, the experience of one country with payment systems and
financial incentives cannot easily be reproduced in another country – even if
there is a high degree of cultural and institutional similarities.
Much has been published on effects of payment systems and financial
incentives on (primary care) physician behaviour. However, most of these publications cover the intended and expected effects of payments systems and
financial incentives only. Moreover, empirical evidence from studies with high
methodological standards is scarce. Accordingly, policy-makers should be very
careful about the distinction between intended and actual effects. The methodological standards alone probably make the results of studies into elements of
payment systems less applicable. The available evidence suggests that fee-forservice payment systems tend to increase the volume of services provided to
patients. This tendency towards overprovision may be harmful for patients and
costly to society – which is the reason why health authorities and/or health
insurers try to limit the volume of services. Fee-for-service payment systems are
usually combined with a free choice of physicians which increases opportunities to choose for the patient but in turn also decreases incentives for a well
coordinated primary care system. Policy-makers should be aware of this tradeoff. Primary care providers paid by salary or capitation in underfunded health
196 Primary care in the driver’s seat?
care systems have high incentives to either privately treat patients and/or to
raise informal user charges. Both practices can endanger access to primary
health care for those people needing it most. Thus, policy-makers should be
careful to provide adequate funding for salaried primary care physicians in
order to reap the potential advantages of salaries – high income security for
primary care physicians, high accessibility for patients and low transaction
costs for society.
There is a trend towards underprovision of services in capitation payment
systems. Since capitation payment systems are usually combined with fixed
patient lists and a gatekeeping function of the primary care physician, they also
restrict opportunities of choice for patients. At the same time they provide large
incentives for providing comprehensive and well-coordinated primary care and
have low transaction costs for society. However, policy-makers should make
sure that they adjust capitation payments for the morbidity of individual
patients in order to minimize incentives for the physician to raise income by
selecting risks. This is especially true in integrated capitation payment systems
where primary care physicians act as fundholders for services in secondary care
or for services provided by other care providers.
Alternatively, the idea of gatekeeping might be at odds with the preferences of
modern and self-conscious health care consumers. We should think about ways
to reconcile these two aspects. For one, the increasing scale of general practice
makes it possible for patients to have more choice within the panel of GPs
working in one practice. The issue of gatekeeping as restriction of consumer
freedom could be solved in the way Denmark did, with its two insurance types,
one giving more freedom but asking more cost sharing and the other restricting
freedom in return for no cost sharing. One danger of the coexistence of a dual
system (which – by the way – does not seem to apply to Denmark) is that those
willing to accept restrictions on their freedom of choice are usually a healthy
selection from the population. This is, for example, the case in Health Maintenance Organizations in the United States and it also seems to be the case in
Switzerland (Colombo, 2001).
Payment systems are not the most influential factor that steers professional
behaviour, but the one that is easiest for policy-makers to modify. This being the
case, policy-makers should make sure that – if they cannot resist the urge to
reform doctor’s payment systems – at least the financial incentives for different
providers are aligned. If you combine capitation payment for GPs with salaried
specialists (as in the United Kingdom), you risk having waiting lists for specialist
care. If you combine capitation payment for GPs with fee-for-service payment
for specialists, you run the risk of excess referrals and high expenditures for
specialist care – though the comparatively low referral rates of Dutch GPs do not
support this hypothesis (Fleming, 1993). It is exactly this type of empirical
“exceptions” to common sense expectations about the effect of payment systems that underlines the basic argument with which we started this chapter:
payment systems work within and in interaction with a broader institutional
context. This institutional context can reinforce or counteract the incentives
embedded in payment systems. Therefore, we should try to research the effects
of payment systems as part of configurations of health care system elements.
Managing primary care behaviour through payment systems 197
Notes
1 However, it is important to note that our chapter is still very much focused on financial incentives for primary care doctors – although we take into account health system
context. We mention other incentives – such as working conditions or career
opportunities – only marginally and where appropriate, since extensive treatment of
them would constitute another chapter. For an overview on non-financial incentives
see Chaix-Couturier et al. (2000).
2 The revitalization of the fundholding idea in the British National Health Service is
called Practice-Based Commissioning. From April 2005, individual GP practices are
given the opportunity to hold budgets for primary and secondary care of their
patients. Primary Care Trusts themselves will continue to be legally responsible for
the contracting process, but any savings which result from managing referrals more
efficiently will be shared between practices and PCTs, with all of those savings being
reinvested into patient care (Department of Health, 2004).
3 Interestingly enough, some GPs opted not to have any incentives linked to their
targets. They refused payment related to their performance since they consider fulfilling these targets as part of their job anyway.
4 Of course there are non-financial incentives which also influence physician
behaviour. According to De Maeseneer et al. (1999) they can be grouped into factors
referring to patient characteristics (number and type of disease, acute versus chronic
diseases, diagnostic versus therapeutic procedures and ability to pay), personal characteristics of the physician (age, gender, experience, qualification) and his or her
organizational environment (individual versus group practice, level of local competition, volume of activity).
5 In most European countries tax-financed or contribution-based systems exist as well
as private health insurance – and primary care providers realize income from different
sources via different payment systems.
6 This is nicely illustrated in a recent Norwegian study (Grytten and Sörensen, 2001).
The study compared fee-for-service primary care physicians and their salaried
colleagues with regard to their response to increased competition. Neither of the two
groups of physicians increased their output as a response to an increase in physician
density. This could be expected for the salaried group while it provides evidence
against the inducement hypothesis for fee-for-service physicians.
7 Incentives for physicians to induce demand are of course only effective if marginal
cost for the production of health care services is less than marginal income. Another
pre-condition is uncertainty about the appropriate treatment – if there are standardized and well-documented guidelines it is much more difficult to induce demand for
physicians (Flierman and Groenewegen, 1992). Finally incentives for supplierinduced demand are higher if there is oversupply of primary care physicians –
physicians may have low workload and may try to reach their target income. See also
Gosden et al. (2001).
8 However, a recent study from the United Kingdom shows that GP morale and job
satisfactions do not necessarily have to be lower in salaried systems than in capitation/fee-for-service systems. Salaried contracts in the United Kingdom are associated
with lower stress levels, higher satisfaction with income and hours of work and the
same levels of overall satisfaction as those of non-salaried GPs (Gosden et al., 2002).
This trend is an example of the fact that payment systems can have different effects
depending on whether they are the dominant system or not. Salaried GPs in the
United Kingdom are a small minority and the situation would probably be quite
different if all GPs in the United Kingdom were salaried.
9 For example, the formal remuneration of physicians in Poland is relatively low and
198 Primary care in the driver’s seat?
provides few pecuniary incentives to work. Remuneration is poor not only in comparison with other sectors of the economy but also vis-à-vis the rest of the public
sector. The average monthly salary in the health sector in 1996 was 84% of the average salary for the public sector. Salaries are often supplemented by payments for
private sector consultations and by informal out-of-pocket payments which constitute an important source of earnings for providers. According to a study estimating
health care expenditures in Poland for 1994, informal payments by patients to physicians contribute to as much as double of the physician’s salary (Chawla et al., 1998).
A more recent study estimates that 40% of health care expenditures are still financed
by informal payments (McMenamin and Timonen, 2002).
10 This development is illustrated by the “Managed Care Backlash” in the United States.
The market share of fee-for-service health care plans is rising again – with more choice
of providers but higher user charges and/or higher premiums (Draper et al., 2002).
References
Albreht, T., Cesen, M., Hindle, D. et al. (2002). Health Care Systems in Transition: Slovenia.
Copenhagen: European Observatory on Health Care Systems.
Atkin, K., Hirst, M., Lunt, N. and Parker, G. (1994). The role and self-perceived training
needs of nurses employed in general practice: observations from a national census of
practice nurses in England and Wales, Journal of Advanced Nursing, 20(1): 46–52.
Boerma, W.G.W. and Fleming, D.M. (1998). The Role of General Practice in Primary Health
Care. London: World Health Organization.
Boyden, A. and Carter, R. (2000). The appropriate use of financial incentives to encourage
preventive care in general practice. West Heidelberg, Centre for Health Program Evaluation, Research Report 18.
Busse, R. (2000a). Health Care Systems in Transition: Czech Republic. Copenhagen: European
Observatory on Health Care Systems.
Busse, R. (2000b). Health Care Systems in Transition: Germany. Copenhagen: European
Observatory on Health Care Systems.
Chaix-Couturier, C., Durand-Zaleski, I., Jolly, D. and Durieux, P. (2000). Effects of financial incentives on medical practice: results from a systematic review of the literature
and methodological issues, International Journal for Quality in Health Care, 12(2):
133–142.
Chawla, M., Berman, P. and Kawiorska, D. (1998). Financing health services in Poland:
New evidence on private expenditures, Health Economics, 7: 337–346.
Colombo, F. (2001). Towards more choice in social protection? Individual choice of
insurer in basic mandatory health insurance in Switzerland. Labour Market and Social
Policy Occasional Papers No. 53. Paris: OECD.
De Maeseneer, J., Bogaert, K., De Prins, L. and Groenewegen, P.P. (1999). A literature
review, in Brown, S. (ed.) A Literature Review. Physician Funding and Health Care systems
– An International Perspective. London: The Royal College of General Practitioners:
18–32.
Delnoij, D.M.J., Van Merode, G., Paulus, A. and Groenewegen, P.P. (2000). Does general
practitioner gatekeeping curb health care expenditure? Journal of Health Services
Research and Policy, 5(1): 22–26.
Department of Health (2002). Primary Care: GPs’ Fees and Allowances and Superannuation
(http://www.doh.gov.uk/pricare/fees.htm, accessed 13 May 2002).
Department of Health (2004). Practice Based Commissioning. Engaging Practices in Commissioning. London: Department of Health Publications (http://www.dh.gov.uk/
assetRoot/04/09/03/59/04090359.pdf, accessed 21 October 2004).
Managing primary care behaviour through payment systems 199
Dixon, A. (1999). Health Care Systems in Transition: Portugal. Copenhagen: European
Observatory on Health Care Systems.
Donatini, A., Rico, A., D’Ambrosio, M.G., et al. (2001). Health Care Systems in Transition:
Italy. Copenhagen: European Observatory on Health Care Systems.
Draper, D., Hurley, R., Lesser, C. and Strunk, B. (2002). The changing face of managed care,
Health Affairs, 21(1): 11–23.
Engström, S., Foldevi, M. and Borgquist, L. (2001). Is general practice effective? Scandinavian Journal of Primary Health Care, 19: 131–44.
Fleming, D.M. (1993). The European Study of Referrals from Primary to Secondary Care.
Amsterdam: Thesis Publishers.
Flierman, H.A. and Groenewegen, P.P. (1992). Introducing fees for services with professional uncertainty, Health Care Financing Review, 14(1): 107–15.
Gaál, P., Rékassy, B. and Healy, J. (1999). Health Care Systems in Transition: Hungary.
Copenhagen: European Observatory on Health Care Systems.
Gosden, T., Forland, F., Kristiansen, I.S. et al. (2001). Impact of payment method
on behavior of primary care physicians, Journal of Health Services Research and Policy,
6(1): 44–55.
Gosden, T., Forland, F., Kristiansen, I.S. et al. (2004). Capitation, salary, fee-for-service and
mixed systems of payment: effects on the behavior of primary care physicians
(Cochrane Review). The Cochrane Library, Issue 1, 2004. Chichester: John Wiley
& Sons.
Gosden, T., Williams, J., Petchey, R., Leese, B. and Sibbald, B. (2002). Salaried contracts in
UK general practice: a study of job satisfaction and stress, Journal of Health Services
Research and Policy, 7(1): 26–33.
Groenewegen, P.P. and Calnan, M. (1995). Changes in the control of health care systems
in Europe. Implications for professional autonomy, European Journal of Public Health,
5(4): 240–244.
Grytten, J. and Sörensen, R. (2001). Type of contract and supplier-induced demand for
primary physicians in Norway, Journal of Health Economics, 20: 379–393.
Hibble, A. (1995). Practise nurse workload before and after the introduction of
the 1990 contract for general practitioners, British Journal of General Practice, 45(390):
35–37.
Hjortsberg, C. and Ghatnekar, O. (2001). Health Care Systems in Transition: Sweden.
Copenhagen: European Observatory on Health Care Systems.
Hlavacka, S. and Skackova, D. (2000). Health Care Systems in Transition: Slovakia. Copenhagen: European Observatory on Health Care Systems.
Hofmarcher, M.M. and Rack, H. (2001). Health Care Systems in Transition: Austria.
Copenhagen: European Observatory on Health Care Systems.
Hutchinson, B., Birch, J.H.S., Lomas, J., Walter, S.D., Eyles, J. and Stratford-Devai, F.
(2000). Needs-based primary medical care capitation: Development and evaluation of
alternative approaches, Health Care Management Science, 3: 89–99.
Järvelin, J. (2002). Health Care Systems in Transition: Finland. Copenhagen: European
Observatory on Health Care Systems.
Jegers, M., Kesteloot, K., De Graeve, D. and Gilles, W. (2002). A typology for provider
payment systems in health care, Health Policy, 60: 255–273.
Karski, J.B. and Koronkiewicz, A. (1999). Health Care Systems in Transition: Poland.
Copenhagen: European Observatory on Health Care Systems.
Kerr, E. (1999). Health Care Systems in Transition: Luxembourg. Copenhagen: European
Observatory on Health Care Systems.
Kerr, E. (2000). Health Care Systems in Transition: Belgium. Copenhagen: European Observatory on Health Care Systems.
Lynch, M. (1998). Financial incentives and primary care provision in Britain: do general
200 Primary care in the driver’s seat?
practitioners maximise their income? in Zweifel, P. (ed.) Health, the Medical Profession
and Regulation. Boston/Dordrecht/London: Kluwer Academic Publishers.
McMenamin, I. and Timonen, V. (2002). Poland’s health reform: politics, markets and
informal payments, Journal of Social Policy, 31(1): 103–18.
Rico, A. (2000). Health Care Systems in Transition: Spain. Copenhagen: European Observatory on Health Care Systems.
Robinson, J. (2001). Theory and practice in the design of physician payment systems, The
Milbank Quarterly, 79(2): 149–77.
Robinson, R. (1999). Health Care Systems in Transition: United Kingdom. Copenhagen:
European Observatory on Health Care Systems.
Starfield, B. (1996). Is strong primary care good for health outcomes? in Griffin, J. (ed.) The
Future of Primary Care: Papers for a Symposium held on 13 September 1995. London:
Office of Health Economics.
Tragakes, E. and Polyzos, N. (1996). Health Care Systems in Transition: Greece. Copenhagen:
European Observatory on Health Care Systems.
Vallgarda, S., Krasnik, A. and Vrangbaek, K. (2001). Health Care Systems in Transition:
Denmark. Copenhagen: European Observatory on Health Care Systems.
Vendramini, E. (2002). Budgets for general practitioners: an Italian survey, Paper presented at the European Health Management Organization Conference in Gdansk,
26–28 June, 2002.
Wilton, P. and Smith, R. (2002). Devolved budgetary responsibility in primary care,
European Journal of Health Economics, 3(1): 17–25.
part
two
Changing institutional
arrangements 83
Changing working
arrangements 147
Changing quality standards 201
chapter
eleven
Improving the quality and
performance of primary care
Richard Baker, Michel Wensing and
Bernhard Gibis
Introduction
Two features distinguish methods for improving quality and performance in
primary care. The first is the relatively rapid adoption of quality enhancing
systems throughout western Europe during the past 15 years, followed by the
start of their introduction in central and eastern Europe (CEE), in the context of
a pan-European trend towards a more important role for primary care in health
services. The second is the extent of diversity in the choice of systems and
approaches. In the first section of this chapter, we define what we mean by
improvement of quality and performance. We then outline some of the
methods of quality improvement employed in primary care in Europe, and
summarize evidence about the effectiveness of these methods. Progress in
different countries is then considered, with countries being placed into one of
three groups according to the level of development of quality improvement
systems. We then discuss trends towards the emergence of common European
standards and the growing importance of patient involvement in quality
improvement activities. In the final section, we consider the implications of
these trends and reflect on the requirements for successful quality improvement
programmes in primary care.
An outline of the characteristics of health systems and health service reforms
in different countries is not included since these are described in detail in other
chapters. Also, we do not deal with the use of high-level strategies to influence
the quality of care, for example, purchasing arrangements, managed competition or regulation. Our focus is on the first-line clinical and preventive care
delivered by GPs, primary care nurses and nurse practitioners, and the teams
in which they work. Since primary care professionals have a varied but often
204
Primary care in the driver’s seat
central position in health care systems, sound quality improvement processes in
primary care are of wide importance.
Quality and quality improvement
Among the many definitions of quality in health care, one proposed by
Donabedian (1980) is particularly helpful: “quality is a property of, and a
judgement upon, an element of care”. The concept of judgement is the key to
understanding the meaning of quality – different judges will come to different
conclusions, according to their own preferences and priorities. Donabedian
suggested that the judges could be categorized into three groups, and in this
chapter we will call these groups patients (to include all current, past and potential future users of health care), professionals (all health care professionals) and
planners (to include policy-makers, funders and managers). But patients, professionals and planners cannot be expected always to agree on the desirable
features of care.
The balancing mechanism lies in the mix of professional regulation, national
legislation and health service polices and guidelines that govern clinical practice (Baker, 2001; Baker and Grol, 2002). These explicit statements are supplemented by implicit codes of behaviour that circumscribe the relationship
between doctors and society. The societies in which we live, therefore, make the
ultimate decisions about whose concerns have priority, or in other words, who
has the authority to define particular elements of quality and set standards of
performance. The process of adoption of quality improvement methods and
programmes in European primary care illustrates not only the varying natures
of our different societies, but also three general trends – the first involves the
gradual replacement of the implicit codes governing professional/patient relations with explicit rules and regulations, the second involves a more equal sharing of power between the three judges of quality, and a consequent reduction of
power among professionals, and the third involves the increasing status of the
GP within health services in most countries.
From the 1980s onwards a variety of quality improvement methods have
been taken up by primary care professionals (Grol et al., 1994; Grol et al., 1997),
and in most European countries various methods are being used and supporting
structures have been introduced. However, the extent to which the trends
towards explicit codes and power transfer have occurred has varied. The principal influence on this process has been the level of development of primary care
services in each country, with those countries with more developed primary
care being first to introduce quality improvement programmes. Additional
influences include cultural attitudes towards professionals in different countries, the unpredictable occurrence of serious adverse events in health care, the
structure of health systems and the place of primary care in those systems and
the existence of coherent leadership within the profession of family practice.
Quality improvement methods share three key elements. The first is the
specification of desired performance, either in the form of clinical guidelines,
care pathways, review criteria or clinical policies. The second element consists of
various ways of changing clinical practice. Numerous approaches have been
Improving the quality and performance of primary care 205
used, all with variable degrees of success. They include lectures, small group
education, one-to-one educational outreach visits, audit and feedback,
reminder systems, computerized decision support, and patient mediated interventions such as guidelines for patients or training to increase patient assertiveness in consultations. The third element is measurement. Performance must be
measured in order to determine whether improvement has occurred, and to
what extent, so that further strategies to change performance may be appropriately targeted. Usually performance is measured before the use of change strategies, and again afterwards, and this process is often depicted as a cycle – the
quality improvement cycle (Figure 11.1).
Since change is unpredictable, measurement often has to be repeated several
times, and in recent years attention has turned towards the introduction of
monitoring systems to collect data about aspects of performance on a continuing
basis. The improved availability of performance data is increasing pressure for
public disclosure of the performance of providers and also making possible the
use of techniques borrowed from industry such as control charts, and it is likely
that such developments will become widespread in the near future (NICE, 2002).
The diffusion of quality improvement in primary care
throughout Europe
In 1981 the Regional Office for Europe of the World Health Organization
(WHO) launched a Model Health Care Programmes and Quality Assurance initiative. Although some localized quality improvement activities had been
undertaken by small numbers of primary care professionals before then, it was
from this point that quality improvement in health care began to be regarded as
an important topic by leaders of health professions and the planners of services
in Europe.
Figure 11.1 The quality improvement cycle
206
Primary care in the driver’s seat
Health professionals have taken a lead in promoting quality improvement.
For example, in 1994 the European Union of General Practitioners (UEMO)
issued a statement on quality improvement which advised governments and
the EU to commit to implementing quality improvement systems for general
practice that included adequate resources for the creation of support structures,
education on quality improvement, and the employment of a variety of specific
methods (UEMO, 1997). The document argued that quality improvement
should be a “priority for all GPs, a part of their normal professional life, and
actions should be taken urgently to promote such an attitude”. The European
section of the World Organization of National Academies and Colleges of
General Practice and Family Medicine (WONCA) established the European
Working Party on Quality in Family Practice (EQuiP) in 1992 under the chairmanship of Richard Grol and with members drawn from six countries. By 2002,
EQuiP had delegates from 27 European countries, including many of the
reformed nations of CEE.
Acceptance by policy-makers of the need for quality improvement systems in
primary care was signalled by in recommendation R (97)17 of the Council of
Europe issued in 1997. This advised the 44 member countries of the Council (as
of 2004) on the establishment of quality improvement programmes in health
care, including primary care. The conditions highlighted as important to establishing quality improvement were policies, including laws, regulations and mission statements; structures, including local and national committees and
boards; and resources, including staff to undertake specific quality improvement activities, time and money for professionals and teams, education and
tools such as computer facilities.
The progressive introduction of quality improvement in an increasing number of countries has had two elements – the introduction of national policies
and funding to create quality improvement programmes of various types and
the use of a growing number of specific methods.
Methods used and evidence on their effectiveness
In this section we outline the more commonly used quality improvement
methods, and consider their effectiveness. A wide variety of quality improvement methods are available, and different methods have been more or less
popular in different countries (Table 11.1). Surveys undertaken by EQuiP in the
early and mid-1990s provide some information (Grol et al., 1994; Grol et al.,
1997), although more recent data about activities are limited. Chart audit and
patient surveys were common in both 1991–2 and 1994–5 as means of collecting data, but by 1994–5, a growing number of countries had improved computer record systems that supported computerized monitoring of performance.
With regard to methods of changing performance, written educational materials,
courses and CME, and small group education tended to be used most commonly
(Table 11.2). However, CME methods are relatively ineffective in promoting
changes in performance and we do not discuss them in detail here.
The research literature shows that quality improvement can be effective in
primary care, but also that none of the methods is always effective (Table 11.3).
Improving the quality and performance of primary care 207
Table 11.1 Methods used to collect performance data in European countries in 1991–2
and 1994–5
Outcome or morbidity data
Data on utilisation/costs
Patient surveys
Chart audit
Computerized monitoring
1991–2 (n=17)*
1994–5 (n=26)**
N
%
N
%
14
13
14
14
–
82.4
76.5
82.3
82.3
–
20
19
18
14
14
76.9
73.1
69.2
53.8
53.8
Sources: Grol et al. (1994), Grol et al. (1997).
Table 11.2 Methods used to implement change in performance in European countries,
1991–2 and 1994–5
Written educational materials
Courses, CME
Small group education
Peer review groups
Practice visits
Continuous quality improvement/
quality circles
1991–2 (n=17)
1994–5 (n=26)
N
%
N
%
17
17
17
12
10
8
100
100
100
70.6
58.8
47.1
26
26
25
15
13
11
100
100
96.2
57.7
50.0
42.3
Sources: Grol et al. (1994), Grol et al. (1997).
Passive education, such as written materials and courses, tends to be less effective, while multifacted interventions tend to be more effective. These conclusions are consistent with the wider research literature on quality improvement
strategies (Bero et al., 1998).
Quality circles/peer review groups
Although the term “quality circle” is used in industry to refer to a specific type of
group convened within the framework of total quality programmes, in primary
care in Europe the term is used synonymously with peer review groups. Typically, peer review is undertaken by a group of 5–10 professionals who meet
together at regular, intervals over an extended period (Grol, 1994). The activities
undertaken include setting criteria, data collection, evaluation of each other’s
work, and making specific arrangements for achieving change in performance.
The first experiments with peer review groups took place in the Netherlands in
the early 1980s. Initial experience was positive, and the Dutch Association of
208 Primary care in the driver’s seat
Table 11.3 Reviews of continuing education and quality improvement in primary care
Author
Area (number of
studies)
Conclusions
Buntinx et al.
(1993)
Preventive and
diagnostic test
ordering (26)
Varying effects: 5–50% improvement on volume
measures. Reminders appear to be more effective
than feedback on adherence to clinical guidelines.
Hulscher et al.
(1999)
Prevention (58)
Post intervention differences between intervention
and control groups varied widely within and across
categories of interventions. Most interventions
were found to be effective in some studies, but not
effective in other studies.
Lancaster et al.
(1998)
Smoking
cessation
(unclear)
Clear improvement of process of care. One in
50 patients who received advice to stop smoking
decided to stop smoking.
Wensing et al.
(1998)
All areas
included (61)
Information transfer alone was effective in 2 out
of 18 groups, whereas combinations of information
transfer and learning through social influence or
management support were effective in 4 out of
8 and 3 out of 7 groups respectively. Information
linked to performance was effective in 10 out of 15
groups, but the combination of information
transfer and information linked to performance
was effective in only 3 out of 20 groups.
Worrall et al.
(1997)
All areas
included (13)
Six studies involved reminder systems, while the
others used small group workshops or education
sessions. Five out of 13 studies showed significant
effects on patient outcomes.
GPs decided to make participation in peer review groups a compulsory part of a
quality assurance and recertification scheme.
Experience in the Netherlands has influenced the adoption of peer review
groups in other countries. For example, the successful CME groups in Ireland
have gradually evolved to include peer review activities (Boland, 1991), and
quality circles were introduced in Germany from 1993, where moderators have
received training and a substantial national programme is now operational
(Gerlach and Beyer, 1998). However, in Germany concerns have arisen that
some groups are not adequately moderated and the efforts of the regional
associations to support the groups differ markedly. Participation has been voluntary and the methods used by the circles are variable and have not been
adequately monitored (Gerlach et al., 1999).
Peer review groups may be particularly suited to countries in which primary
care is largely provided by solo GPs. The regular group meetings enable such
practitioners to meet their peers and exchange ideas. In countries in which large
primary care teams predominate, other quality improvement systems tend to be
preferred. There is limited evidence on small group quality improvement as a
Improving the quality and performance of primary care 209
single strategy, but it suggests that it can be effective. Studies on the improvement of prevention in primary care showed effects in the range −4% to +31%
(Hulscher et al., 1999). Training health professionals to help patients stop smoking resulted in higher numbers of patients who received advice on smoking,
made appointments about stopping, etc. (Lancaster et al., 1998).
Practice visiting
Practice visiting has been implemented in several countries. The experience in
Sweden offers an example. Data are collected in preparation for the visit and
after the visit feedback is provided to promote reflection. Although the activity
involves several professionals at once, and takes time, it is reported as being
beneficial, and as overcoming the isolation that can sometimes occur in primary
care (Eliasson et al., 1998).
In the United Kingdom, practice visits were introduced in the 1970s in order
to assess those practices that wished to undertake the training of new GPs. In
1990 the Royal College of General Practitioners introduced a system of awarding fellowships by assessment of performance to GPs who could demonstrate
particularly high standards. Explicit criteria were developed, and the method of
assessment involved observation of the doctor consulting (usually on videotape) and a visit to the practice to assess procedures and interview the doctor.
This system has since been developed for the award of membership of the college. The Quality Practice Award (QPA) is a further method intended for primary
care teams who wish to achieve recognition of high-quality patient care. The
practice submits evidence to the college about aspects of its performance, and
an assessment visit is undertaken. A development of this approach involves the
engagement of the practice team in a development programme (Macfarlane
et al., 2004).
Experience of schemes such as these suggest that practice visits can serve to
challenge practitioners and teams to review and improve their performance,
and an international team is evaluating a system intended for wide use in
Europe (Elwyn et al., 2004). They also provide some recognition of high standards. In enabling the exchange of ideas, they represent one alternative to peer
review groups in those countries in which group practice is common. Two studies on prevention in primary care showed a large difference in effects (5 and 44%
change) (Hulscher et al., 1999). A review of this approach in all health care
sectors identified three studies, which showed a range of effects of 24 to 50%
(Thomson et al., 1998).
Guidelines
In most countries arrangements are in place to produce national guidelines in
order to influence the performance of primary care professionals. GPs in the
Netherlands were among the first to introduce national guideline development
programmes and their experience is an example of what can be achieved.
Clinical guidelines currently comprise the core of the quality improvement
210
Primary care in the driver’s seat
activities of the Dutch College of General Practitioners (NHG). Since 1989 about
70 national guidelines have been developed on a wide range of diseases and
complaints (Timmermans and In ‘t Veld, 2001). A structured development procedure is used, which combines systematic assessment of the research evidence
and the judgement of experienced GPs. The guidelines are updated on a regular
basis and published in the scientific journal of the Dutch College. The college
supports the implementation of the guidelines by developing a range of
materials, including cards that summarize the content of the guideline, packages for individual and group education, knowledge tests, written patient
information materials, an electronic prescribing system, and practice visits by
trained practice consultants (Timmermans and In ‘t Veld, 2001). The guidelines
are also used in the vocational training of GPs. A large study in 1999 showed
that adherence to the guidelines was overall 67%, with considerable variation
across GPs, consultations and specific recommendations (Spies and Mokkink,
1999). In recent years, a recognition that guideline implementation and quality
improvement have taken too much of a top-down approach has prompted the
college set up a service to identify GPs’ needs at local level, provide advice and
stimulate local learning and improvement.
The Netherlands illustrates one model of guidelines development in which
health professionals take the lead. In some other countries, governments have
set up national agencies to provide guidelines, and generally cost-effectiveness
of clinical interventions is taken into account rather than merely effectiveness.
Thus, the governments in these countries see guidelines as being a mechanism
to minimize expenditure on relatively ineffective treatments, and to ensure
equity of access to effective care.
Audit
Audit has been defined in various ways. The broadest definition, and the one
most commonly assumed by health professionals, has been framed as “a quality
improvement process that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and the implementation of
change” (NICE, 2002). This view of audit adheres closely to the quality
improvement cycle (Figure 11.1) and incorporates the use of a wide range of
activities to implement change, from simple educational interventions to revision of systems of care. A narrower definition of audit limits the term to the
collection of data about performance. Research evaluations of the effectiveness
of audit generally adopt this definition, and restrict the method of implementing change to feedback of data about performance to health professionals.
Audit projects led by health professionals themselves have been shown to
achieve both participation and improvements in aspects of care in Denmark
(Munck et al., 1999) and Sweden (Melander et al., 1999). This experience has
also been applied in Iceland and Norway (Munck et al., 1998). Audit has played
a major role in quality improvement activities in the United Kingdom from
1991. The combination of new health service policy, a limited amount of funding and local structures to provide leadership and encouragement, led to the
participation of most health professionals in primary care in audit projects.
Improving the quality and performance of primary care 211
General practices have reported taking part in a median of three projects
each per year, with changes in care being implemented in two-thirds of the
audits (Hearnshaw et al., 1998a). Most audits were concerned with aspects of
clinical care.
Audit with feedback can (but does not always) lead to improved performance,
but the evidence indicates that the effects are often small. A review of 22 studies
on the improvement of prevention in primary care showed the effects of audit
and feedback lay in the range of 4 to 26% improvement (Hulscher et al., 1999).
A review of test ordering, which covered all health care sectors, showed that
feedback led to changes in 13 out of 21 studies (Solomon et al., 1998).
Quality management techniques
Since primary care providers are usually very small organizations, commercial
quality improvement methods have required some adaptation prior to use in
this sector. Nevertheless, there are examples of projects in which these methods
have been evaluated, for example in the Netherlands (Geboers et al., 1999) and
the United Kingdom (Hearnshaw et al., 1998b). More recently, some countries
have begun to introduce collaborative programmes, working in partnership
with the Institute for Healthcare Improvement in Boston (http://www.ihi.org).
The National Primary Care Collaborative in the United Kingdom is an example.
By 2004, this had engaged 5000 general practices caring for 32 million patients
in introducing shorter waiting times and other improvements, making this the
largest health improvement programme worldwide (National Primary Care
Development Team, 2004). Almost certainly, these methods will be used more
widely in the future.
Another initiative is the establishment of accreditation schemes in German
ambulatory health care. Accreditation (called practice certification in Germany)
schemes are aimed primarily at specialist care, but increasingly GP practices
will seek accreditation with respected bodies. So far no validated accreditation
system has been established in Germany for GP ambulatory health care and
various for-profit and not-for-profit institutions offer products. These are
mainly based on the DIN-ISO model adapted to the requirement of small private
practices, or the EFQM model, which is a European adaptation of the Malcom
Baldridge award.
National policies on quality improvement in primary care
In the EQuiP survey of 17 European countries in 1991–2, six had national
policies on quality improvement in family practice (Denmark, Iceland, the
Netherlands, Norway, Sweden, the United Kingdom) (Grol et al., 1994). The
policies involved national governments and professional organizations, and
included funding and legislation. Seven countries had policies under development (Finland, Germany, Hungary, Ireland, Israel, Portugal, Spain), and four
countries neither had a policy nor plans to develop a policy (Belgium, the Czech
Republic, France, Italy). The respondents to this survey were asked about factors
212
Primary care in the driver’s seat
they believed were required in order to implement quality improvement, and
the factors most frequently cited were resources including money and staff, and
support structures such as professional committees; education on quality
improvement techniques; policies that included leadership from planners and
professional bodies backed by political and financial support; research into
effective methods of quality improvement; activities to increase interest and
motivation towards quality improvement among GPs; clinical guidelines; and
collaboration between European countries to exchange ideas and experiences.
The survey was repeated in 1994–5, this time including 26 countries (21 from
Europe, plus Australia, Canada, Hong Kong, New Zealand and the United States)
(Grol et al., 1997). It was evident that in a relatively short time, progress had
been made in many countries. Sixteen countries reported having national
boards and networks for quality improvement, 11 had specific training programmes and 10 had a legal framework addressing quality improvement in one
way or another. In 20 countries, academic and professional organizations were
providing a lead in promoting quality improvement in primary care. Despite
these signs of progress, the study confirmed that quality improvement activities
were, at that time, a relatively new endeavour in most European countries.
No country had reached the point at which quality improvement had become
a normal part of daily work for primary health care professionals. The most
commonly expressed need in order to increase quality improvement activity
(mentioned by 10 countries) remained resources such as financial support, extra
time or dedicated staff. The creation of a positive attitude towards quality
improvement among GPs was mentioned by respondents from eight countries;
education, political support and rewards or incentives were each mentioned by
five, and four mentioned a need for better indicators and quality improvement
tools.
In general, policies emerged at an earlier date in the countries of Scandinavia
and western Europe in comparison with the CEE countries. In the following
section, we present brief outlines of progress in selected countries, grouped into
those countries that were first to introduce quality improvement systems (the
first wave), those that quickly followed suit (the second wave), and those now in
the process of introducing quality improvement systems. For the most part, we
draw on reports from EQuiP.
The first wave
By 1992 all the countries in this group had made considerable progress in introducing national policies on quality improvement in primary care, supported
either by local structures, a legal framework or formal accreditation systems.
They also tended to have well-developed primary health care systems associated
with high professional status for GPs, including for example national colleges or
associations and established training schemes. For example, in 1992, the proportions of GPs who were members of national colleges were: Denmark 100%,
Finland 70%, Iceland 95% the Netherlands 90%, Sweden 95%, and the United
Kingdom 60% (Grol et al., 1994). In most of these countries, the initial policies
have been further developed in recent years, involving both more expenditure
Improving the quality and performance of primary care 213
on quality improvement and greater obligations on GPs and practices to take
part. Thus, quality improvement systems have increasingly become integral
features of health services.
Denmark
By the early 1990s Denmark had a national policy, local structures and an
accreditation system, and many GPs were taking part in audit projects. In 1995 a
new agreement between the Danish Association of General Practitioners and
the National Health Insurance was reached that included a charter on quality
improvement. Funding was made available and local authorities set up quality
improvement committees. The committees were tasked with developing local
policies and leading practical projects. Plans were also agreed for the development of national guidelines (Jensen, 1996), and the college of GPs began development of national guidelines in 1998–9. The guidelines have been used in the
context of local groups of which all GPs are members. Quality development
activities are funded locally, with a range of projects including outreach visits to
practitioners. In addition, a system for coordinating care across the boundary
with hospitals has been established (Olesen and Jensen, 1999).
Finland
Although a national policy was only partly operational by 1992, a legal framework was under development and formal accreditation was in operation. Professionals had become interested in quality improvement in the late 1980s,
and a national training project was instituted in the mid-1990s, the training
being delivered through health centres. A national policy statement was
issued in 1996, all providers being encouraged to formulate a policy on quality
improvement. Guidelines for GPs became available from 1991 in electronic
form (Makela, 1996). The national recommendations on quality management
were updated in 1999, and they advised health care organizations to develop
regular patient feedback, provide continuing education for staff, and make
use of guidelines. National projects undertaken by health centres include a continuing review of care for people with diabetes and another for those with
hypertension.
Iceland
A national policy on quality improvement emerged at an early stage, associated
with a formal accreditation scheme, and promotion by government and professional organizations. Activities included annual practice plans and target setting, and work with patient groups. In the mid-1990s a quality development
committee was established, and computerized records introduced. The Icelandic College of Family Physicians has a Quality Council, which has the task of
organizing activities. These have included the promotion of local quality circles
and the conduct of a patient survey (Gudmundsson and Mixa, 1998).
214 Primary care in the driver’s seat
The Netherlands
Quality improvement in primary care has been initiated and coordinated by
the profession, encouraged by the government. Since the 1980s, professional
organizations have national programmes for the development and implementation of clinical guidelines and for continuing education through peer review
groups. Laws have been established that arrange professional autonomy,
patients’ rights on informed choice, and quality management in health care
organizations (1996 Quality Law, or Kwaliteitswet). The law on professional
autonomy prescribes a required level of quality improvement that is needed for
recertification as a professional. The law on quality management is relevant for
practices with two or more GPs. It requires that the practice publish annual
quality reports to account for the quality of care delivered and for efforts to
improve quality. A GP can meet the requirements of these laws by participation
in the profession’s quality improvement programmes. National policies on
quality improvement have been agreed upon at special, five-yearly conferences
in which organizations of health care providers, patients, insurers and the
government participate.
Sweden
By 1992 Sweden had begun to implement a legal framework for quality
improvement activities, had a national policy, local structures and an accreditation scheme. Training on quality improvement became widespread following
new legislation in 1994. Extensive use was made of a collection of methods for
quality improvement, contained in a Quality Tool Box developed by EQuiP
(Persson, 1995). A National Board was established in 1997, backed by new legislation, to allocate funds to county councils for quality improvement activities
that included audit. The legislation required local systems to include methods
for responding to patient views and complaints, and ways to ensure the clinical
competence of professionals (Persson, 1997).
The United Kingdom
A few GPs began to undertake audit from the 1970s, and by 1983, the Royal
College of General Practitioners had adopted a goal that within 10 years, all GPs
should incorporate standard setting and performance review as an integral part
of their professional lives. 1991 saw the introduction of local organizations
(medical audit advisory groups) to support and facilitate audit by all GPs and
primary health care teams. Limited funds were provided to enable these groups
to function, although participation in audit was voluntary. In 1998, a new mandatory system – clinical governance – was introduced, that incorporated audit
into a wider collection of quality improvement activities. At the same time, a
national body for guideline development was created. Since then, other national
agencies have been set up to lead developments in patient safety (Rubin et al.,
2003) and address poor performance among a limited number of doctors. In
2004, a major development in quality improvement took place. A new
incentive-based contract for general practitioners was introduced, payment
Improving the quality and performance of primary care 215
being linked to the achievement of targets for the care of selected conditions
and assessment of patients’ experiences (Department of Health, 2003). This is
probably the most advanced example to date of explicit codes defining quality
of care and the transfer of power to determine quality from professionals to
planners.
The second wave
In these countries, systems for quality improvement were less well developed in
the early 1990s, but substantial progress has been made since then. The proportion of GPs who were members of national colleges in 1992 tended to be lower
in most of these countries in comparison with those in the first wave (for
example, Belgium 40%, France 15%, Ireland 95%, Israel 25%, Italy 0%, Portugal
55%, Spain 30%).
Austria
Quality circles were first introduced in 1994, and spread widely under the
leadership of the Austrian Society of General Practitioners (Glehr, 1997). Leaders
of quality circles have received training by the society, and a survey of GPs
has shown that they regard involvement in quality improvement as necessary.
Guidelines have been developed for use by the quality circles (Glehr, 1999),
and a survey of quality circle members has confirmed doctors’ positive views
about them.
Belgium
Guidelines and peer review groups have formed the basis for the quality
improvement system in Belgium since approximately 1995. The review groups
have been supported through training of group leaders, instruction manuals,
and evaluation procedures. Participation in peer review groups is mandatory in
order to obtain accreditation. In addition, some national audits have been
performed, for example on care of people with type 2 diabetes. Self-registration
or audit of aspects of performance by GPs has been established for some years,
and national congresses on quality improvement have been held.
France
The National Agency for the Development of Medical Evaluation (ANDEM) was
created in 1990 to develop guidelines and methods for the evaluation of services, including methods for audits (Doumenc and Lafont, 1997). However, at
that time, there was no comprehensive national policy, legal framework or
local structures for quality improvement activities. In 1997, ANDEM was succeeded by the National Agency for Accreditation and Evaluation in Health Care
(ANAES), which subsequently established local support services for quality
improvement in all regions of the country in 1999. These local services were
given responsibility for raising awareness among local doctors and initiating
audits. Programmes were established for education about quality improvement
216 Primary care in the driver’s seat
and the development of guidelines. (Samuelson, 1999) From 2002, programmes
for both GPs and specialists were established to support voluntary participation
in self-assessment activities. Local leaders have been trained, and given quality
improvement tools to support their work. At the same time, teaching about
quality improvement has been introduced to the medical undergraduate curriculum throughout the country.
Germany
Quality assurance issues are mandated in the Social Code Book 5 for public
health care and through the recommendations of the German medical association for private health care. Despite limited funds for the support of quality
improvement activities, primary care professionals have increasingly initiated
projects. These have included guideline development and quality circles; 1600
quality circles were discovered to be in operation in 1997 (Gerlach and Szecsenyi, 1997). Among other professional organizations, the German Society of
General Practice has established a programme for the development of guidelines
(Gerlach and Szecsenyi, 1998).
The latest developments (such as practice accreditation initiatives and disease
management) show that in public health care quality improvement initiatives
for GP care are changing from a rigid and mandatory approach to quality management. The use of a balanced mix of mandatory directives and stimulation of
voluntary initiatives has been regarded as important.
Ireland
For many years CME groups have been active throughout Ireland. The Irish
College of General Practitioners now has a Quality in Practice Programme that
has established a distance learning programme and supports the local CME
groups. Guidelines have been developed, and during 1999, progress was made
in developing CME groups into quality improvement or peer review groups
(Boland and O’Riordan, 1999).
Italy
A limited number of guidelines had been produced by 1996, generally by specialist societies. Since then, a larger number of guidelines has been published,
and interest in evidence-based medicine has grown rapidly. Local and regional
quality development programmes became included in professionals’ agreements with health authorities from 1997. The Italian Quality Assurance Society
has promoted peer review and quality circles, and the society has a primary care
unit. In addition, several large regional quality improvement projects have been
undertaken.
Portugal
A considerable degree of progress has taken place in Portugal over a relatively
short period of time. The Ministry of Health established a Central Department
Improving the quality and performance of primary care 217
for Promotion and Quality Assurance, which has provided vigorous leadership
as well as practical support. It has instituted several programmes, including for
example a project to monitor outcome indicators in health centres or to
improve patient satisfaction. Guidelines were also being developed (Pisco,
1997). A health strategy was launched in 1998 with the aim of initiating a new,
patient centred culture that would include a total quality health care system.
The MoniQuOr project (Assessment and Monitoring Organizational Quality in
Health Centres) has been one element of the strategy, and has involved the
assessment of all primary health care centres. Prizes have been offered to health
centres providing the highest levels of service.
Switzerland
A small number of quality circles were introduced in the early 1990s, and by
1995 180 circle leaders had been trained. A law came into force in 1996 under
which care providers were obliged to implement quality improvement programmes. Aspects of these programmes could be delivered by professional
organizations, and activities included peer review groups or quality circles
and the development of guidelines (Kuenzi and Egli, 1996). The first national
guideline project was launched in 1997, and addressed low back pain.
Third wave
The third wave is mainly composed of CEE countries. The pre-existing systems
based on the Shemasko model lacked incentives to improve quality, but this
issue is now being addressed in health service reforms. Practice management has
also been poorly developed, and this is being rectified, one benefit being
improved ability to undertake quality improvement at the practice level (Jack
et al., 1997). Furthermore, quality improvement has been regarded as an aid to
raising the often low status of GPs in the health care system, e.g. Bulgaria
(Goranov and Balaskova, 1998) and Slovakia (Jurgova, 1998).
Croatia
The development of a quality improvement programme is recent. Mandatory
recertification for doctors and a patients’ complaints system were the first elements. Professional bodies initiated a national society for quality assurance in
health care in 1998, and at that time voluntary quality improvement activities
among family doctors were increasing, including for example, audits and quality circles (Tiljak, 1998a). Project facilitators have been trained in quality
improvement techniques, and experience has been rolled out to other professionals through workshops and conferences (Tiljak, 1998b). Assistance in training professionals in quality improvement methods has been obtained from
experts in the Netherlands.
218
Primary care in the driver’s seat
Czech Republic
Progress in the Czech Republic has generally been in advance of other CEE
countries. An accreditation system was in operation in the early 1990s, and the
country was the first from CEE to have representation in EQuiP. This was followed by several local quality improvement projects, but the principal task from
the early 1990s was the establishment of the general practice profession. University departments and training programmes underwent development, and
towards the end of the 1990s quality improvement initiatives had begun to
include guideline development and a variety of implementation methods.
Estonia
In Estonia, training for GPs was instituted in 1991 and the Estonian Society
of Family Doctors was established in the same year. By 1995 the society was
organizing meetings on quality improvement (Lember, 1996). Interest in the
use of quality improvement methods has extended to investigation of patient
satisfaction with primary care (Polluste et al., 2000).
Poland
In the reforms that followed the collapse of communism in Poland, a College of
Family Physicians was established in 1992. Quality improvement activities have
not been the first priority during these changes education and professional
development have come first, but quality improvement is now gaining more
importance, and is being introduced into daily practice (Windak, 1998). Representatives from Poland participated in the first International Summer School on
Quality Assurance in General Practice in 1994, these individuals later taking a
leading role in the development of activities in Poland. Although an early
attempt to establish peer review groups failed, quality improvement projects on
topics that included upper respiratory tract infection and hypertension were
implemented (Windak et al., 1998). A National Centre for Quality Assessment
has recently been established, and early work has included preparation for a
patient survey.
Slovenia
Following the declaration of independence in 1991, reforms have been implemented in the health care system. Primary care had been established under the
previous regime, with the provision of premises and the creation of the Slovene
family medicine society in 1966. However, vocational training was slow to
arrive. Interest in quality improvement has increased in the last decade and
courses and teaching materials were readily available from 1994. Attitudes
towards quality improvement are positive among family doctors. Participation
in peer review is now obligatory, and the number of projects undertaken by
primary care professionals to evaluate their own care is increasing (Kersnik,
1997).
Improving the quality and performance of primary care 219
Turkey
In Turkey, reforms have progressed slowly over several decades, the general aim
being to strengthen primary care. Family medicine is still a relatively new discipline and has had to establish itself within the health care system. Vocational
training has been introduced, university departments of general practice established, but quality improvement is at an early stage (Basak and Saatci, 1998).
Activities initiated during 2001 included the administration of a patient survey
to more than 1000 patients, and the creation of a core group to define the
standards for record systems.
Emerging trends
The previous section has demonstrated that quality improvement systems are
being introduced into primary care in most European countries, although at
different speeds in different groups of countries, largely dependent on the level
of development of the profession of general practice. In this section, we briefly
consider two early trends that can be detected, particularly among those countries that embarked on quality improvement first. The first of these is the development of common standards of care and quality improvement systems, and the
second is the increasing role of patients in policy-making and the assessment of
quality.
Common European standards
As with the development of quality improvement within countries, at an international level initial steps have been taken in the field of vocational training,
and in the EU, common standards for training have been agreed. Developments
with regard to clinical care are at an early stage, and most activity has been led
by professional bodies. Several European collaborative groups have emerged,
with a shared interest in a particular condition, such as diabetes or coronary
heart disease. The aim of these groups is to share ideas and generate support for
improved care. Some groups have issued guidelines. One such example is the
recommendations of the joint task force on prevention of coronary heart disease (Wood et al., 1999). However, although these were developed by professionals, the majority were specialists rather than GPs. A statement on improving
care across the interface between primary and secondary care has been issued
(Kvamme et al., 2001), and ideas about a common European view on aspects of
quality improvement have been proposed, for example a statement from EQuiP
on the role of indicators (Lawrence and Olesen, 1997).
Although many national governments have developed and promoted
national clinical guidelines, they have not begun to agree common European
guidelines. There are obvious reasons why this should be the case. Since different countries have different health care systems and different levels of resources
devoted to health care, the uniform application of common clinical standards
across Europe would be virtually impossible. However, in the long term it is
220 Primary care in the driver’s seat
likely that some degree of commonality will emerge in the health care systems
of Europe and common guidelines or standards will then be possible. It is also
conceivable that pressure from professionals and patients in those states that
spend less on health care will accelerate this process.
Patient involvement
The agreement of common European standards is at an early stage, but progress
towards greater involvement of patients is more advanced. This suggests the
existence of a general social movement across Europe for greater empowerment
of patients, and increasing limitations on the power of professionals. At the
level of individual patients, it is now widely accepted that doctors and nurses
should actively seek to involve patients in their own care. General practice has
proved amenable to this development, since it has itself developed a perspective
on the doctor-patient relationship that placed emphasis on the patient’s perspectives and circumstances: the so-called patient-centred clinical method. At
policy level, policy-makers in many countries have responded to the pressure of
patient’s organizations to review complaints systems and to create structures to
enable patients or their respresentatives to take part in decisions about the
design of services. Typically, such developments are most advanced in the countries in the first wave group described above, and in these countries national
guideline development programmes place importance on the involvement of
patient representatives in the agreement of guideline recommendations. The
United Kingdom is one example.
Surveys of patient opinion have also become highly popular, among both
planners and professionals. Large numbers of patients in Europe have been
asked in recent years about their views on the primary care services available to
them. The design of valid survey instruments requires expertise, and several
standard instruments are now available and have been widely used. One
example is the general practice assessment survey (GPAS) that seeks patients’
views of general practice services (Bower et al., 2002), another is the consultation satisfaction questionnaire (CSQ) concerned specifically with consultations in general practice (Baker, 1996), and a third, the patient career diary, is
concerned with the process of referral from general practice to specialist care
(Baker et al., 1999). An international collaborative group of researchers and GPs,
associated with EQuiP, have developed a European standardized questionnaire
for patient evaluations of general practice (EUROPEP) (Grol and Wensing,
2000). This instrument was developed from the start in an international context. The questionnaire (23 items) focuses on patient priorities for general practice, which had been established through surveys among patients in different
countries (see Box 11.1) (Grol et al., 1999). The final version has been translated
into 15 languages: Danish, Dutch, English, Finnish, French, German, Greek,
Hebrew, Icelandic, Norwegian, Portuguese, Slovenian, Spanish, Swedish and
Turkish.
Survey studies in 16 countries in 1999–2000, and including more than 25,000
individuals, showed that patients generally had positive evaluations of general
practice care. For most aspects, 80% of more of patients felt that the care
Improving the quality and performance of primary care 221
Box 11.1 Top-10 patient priorities regarding general practice in Europe
•
•
•
•
•
•
•
•
•
•
Time in the consultation to listen, talk and explain
Quick availability in emergencies
Confidentiality of patient information
Information about the illness
Opportunity to talk about health problems
Possibility of making an appointment at short notice
GP goes to courses about new medical developments
Preventive services
Critical evaluation of medication and advice
Adequate explanation of diagnostics and treatment
received was good or excellent, although considerable variation was found
within countries. For instance, a further analysis showed that patients in practices with few practitioners and few other care providers had more positive
evaluations of the availability of general practice (Wensing et al., 2002). In a
series of studies in the United Kingdom, Baker (1997) has shown not only that
patients prefer smaller practices, but also that many professionals and planners
have preferred larger practices, and as a consequence the proportion of large
practices has increased. Thus, investigation of patients’ views cannot be
assumed to lead to patient involvement in policy-making. Additional methods
are required to ensure that patients or their representatives take part in decisions
about the design and delivery of services. The further development of patient
involvement is likely to depend on the wide introduction of practical methods
suitable for use at the local level, such as citizens’ panels, community consultation groups, or representation in policy-making bodies. Although isolated
examples of such local iniatives can be found in some countries, they are as yet
uncommon.
Conclusions and future developments
In this chapter, we have seen how quality improvement policies and methods
have become widely adopted in primary care in Europe at the same time as the
profession of general practice has become established and primary care in general has been given a more important role in health services. The extent to
which quality improvement has been introduced, however, has varied between
countries. The process appears to depend first on the creation of a profession of
general practice, with both formal training programmes and national leadership
from within the profession itself, generally in the context of a college or association. Once this stage has been reached, some professionals explore quality
improvement methods and then take on the role of convincing others to follow
their lead. In due course, planners recognize the opportunity presented by a
vigorous general practice profession to expand the role of primary care services,
and an integral feature of this development is the introduction of formal
222
Primary care in the driver’s seat
and funded systems to enable quality improvement activities to function. The
process started earliest in the countries of western and northern Europe, but was
quickly taken up in southern Europe. It has also found its way into the reforming health care systems of CEE, although developments in many of these countries are at an early stage. The United Kingdom has advanced in this direction
more than most countries, as illustrated by the work of the state-funded
National Primary Care Development Team and the 2004 contract for general
practitioners based on explicit quality targets.
If we return to the definition of quality outlined at the beginning of this
chapter, it may be surmised that the evolution of quality improvement is a
consequence of the shift in the authority to judge the quality of care from
professionals to patients and planners. However, it has in reality been a more
complex process. The standing of the profession of GPs had to be improved in
almost all countries before quality improvement began, indicating that first of
all, GPs had to acquire some authority over quality and standards. Once GPs had
acquired authority, some among them recognized that the authority should be
shared with planners and patients. The specification of the responsibilities of
professionals for participation in quality improvement in laws or regulations is
an example of the replacement of implicit codes (in this case, GPs are assumed
to act to maintain or improve quality) by explicit rules (GPs are obliged to
maintain or improve quality) as described at the beginning of this chapter. The
introduction of quality improvement can also be regarded as one aspect of the
sharing of authority with planners. As discussed above, patients have yet to be
involved in quality improvement beyond merely the completion of questionnaires and therefore the next stage of sharing authority with patients has only
begun to take place.
Methods of patient involvement have been largely limited to surveys, and any
effect of these activities on the quality or design of services is difficult to detect.
A more fundamental change is required before a genuine sharing of authority
with patients can be achieved. The public disclosure of information about the
performance of services – or individual health professionals – may be one element of the initiatives required to bring this about. Greater patient access to
information about the management of disease may be another element, for
example the provision of guidelines to the public. Permitting patient access to
their own clinical records is another potential element. The role that local consultation systems might play has been outlined above. However, despite the
availability of these approaches, little progress is discernible, even in the first
wave group of countries.
Another challenge is that of achieving genuine improvements in care. Despite the wide adoption of quality improvement activities, convincing evidence about their impact on the quality of care is difficult to find. Research
evidence has shown that some methods can sometimes lead to improvements, but the goal of routine achievement of change in the context of
primary care quality improvement systems has not been attained. The explanation may lie in a failure to identify the most effective approach. If this is the
case, all that is required is to introduce a new approach shown to be promising in another context. The hunt for a new technique that will ensure success
is an old one in the young field of quality improvement research, and the
Improving the quality and performance of primary care 223
most recent example is that of the theory of complex adaptive systems (Plsek,
2001). It is too early to judge whether this approach will indeed prove the
solution to the challenge of changing performance, but the spread of quality
improvement systems described in this chapter contains one lesson that
should not be ignored.
The adoption of quality improvement systems has depended on the preliminary development of the profession of general practice. Once that development has reached a certain level, in almost all countries the initial steps in
quality improvement take place. This reflection leads to the conclusion that to
make quality improvement systems truly effective, we need once again to examine the status of the profession. Restoration or reinvigoration of professionalism
is likely to prove to be the key to the next stage of quality improvement in
Europe. In some ways this is a surprising conclusion given the general assumption of a trend in which patients and planners gain power at the expense of
professionals, yet if professionals have little authority over the quality of care,
they will have very little authority to share with others, and they will have only
limited power to improve the quality.
In some countries, planners have already instituted programmes to improve
leadership in health care institutions. This is an important step in revitalising
the profession, but other steps are also needed. National colleges and associations need to consider reforms to strengthen their ability to promote a culture,
provide standards and create self-esteem that make steady quality improvement
a routine part of the GP’s working life. Planners must also address the many
pressures on GPs caused by increased demands, lack of resources and in some
countries inadequate numbers of doctors and nurses. If the fundamental
impediment to transforming the quality of care is the flagging energy of the
profession, substantial progress cannot be expected until reforms such as these
have been implemented. However, gradual but limited progress will still occur.
Such developments will include progress in those countries that have not yet
firmly established quality improvement programmes. They will have to decide
to commit to necessary resources, and introduce regulations or laws that make
quality improvement an integral component of systems to manage clinical care.
Future developments in all countries are likely to include growing interest in
patient safety and the avoidance of error, and the use of techniques to facilitate
effective teamwork.
References
Baker, R. (1996). Characteristics of practices, general practitioners and patients related
to levels of patients’ satisfaction with consultations, British Journal of General Practice,
46: 601–605.
Baker, R. (1997). Will the future GP remain a personal doctor? British Journal of General
Practice, 47: 831–834.
Baker, R. (2001). Principles of quality improvement. Part one – defining quality, Journal of
Clinical Governance, 9: 89–91.
Baker, R. and Grol, R. (2002). Principles and models for quality improvement, in Jones,
R. (ed.) Oxford Textbook of Primary Medical Care. Oxford: Oxford University Press.
Baker, R., Preston, C., Cheater, F. and Hearnshaw, H. (1999). Measuring patients’ attitudes
224 Primary care in the driver’s seat
to care across the primary/secondary interface: the patient career diary, Quality in
Health Care, 8: 154–160.
Basak, O. and Saatci, E. (1998). The developments of general practice/family medicine in
Turkey, European Journal of General Practice, 4: 126–129.
Bero, L., Grill, R. and Grimshaw, J.M. (1998). Closing the gap between research and practice: an overview of systematic reviews of interventions to promote implementation
of research findings by health care professionals, British Medical Journal, 317: 465–468.
Boland, M. (1991). My brother’s keeper, British Journal of General Practice, 41: 295–300.
Boland, M. and O’Riordan, M. (1999). A report from Ireland, European Journal of General
Practice, 5: 81–82.
Bower, P., Mead, N. and Roland, M. (2002). What dimensions underlie patient responses
to the General Practice Assessment Survey? A factor analytic study, Family Practice, 19:
489–495.
Buntinx, F., Winkens, R., Grol, R. et al. (1993). Influencing diagnostic and preventive
performance in ambulatory care by feedback and reminders. A review, Family Practice,
10: 219–228.
Department of Health (2003). Investing in General Practice: The New General Medical Services
Contract. London: Department of Health. (http://www.dh.gov.uk/assetRoot/04/07/
19/67/04071967.pdf, accessed 28 October 2004).
Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring. Vol. I: The Definition of Quality and Approaches to its Assessment. Ann Arbor: Health Administration
Press.
Doumenc, M. and Lafont, M. (1997). Practice evaluation: what’s new in France? European
Journal of General Practice, 3: 161.
Eliasson, G., Berg, L., Carlsson, P., Lindstrom, K. and Bengtsson, C. (1998). Facilitating
quality improvement in primary health care by practice visiting, Quality in Health
Care, 7: 48–54.
Elwyn, G., Rhydderch, M., Edwards, A. et al. (2004). Assessing organisational development
in primary medical care using a group based assessment: the Maturity Matrix, Quality
and Safety in Health Care, 13: 287–94.
Geboers, H., Van der Horst, M., Mokkink, H. et al. (1999). Setting up improvement projects
in small scale primary care practices: feasibility of a model for continuous quality
improvement, Quality in Health Care, 8: 36–42.
Gerlach, F. and Beyer, M. (1998). New concept for continuous documentation of development of quality circles in ambulatory care: initial results from an information
system in Germany, Quality in Health Care, 7: 55–61.
Gerlach, F. and Szecsenyi, J. (1997). A report from Germany, European Journal of General
Practice, 3: 32.
Gerlach, F. and Szecsenyi, J. (1998). Communication section, European Journal of General
Practice, 4: 171–172.
Gerlach, F.M., Beyer, M. and Romer, A. (1999). Quality circles in ambulatory care: state of
development and future perspective in Germany, International Journal for Quality in
Health Care, 10: 35–42.
Glehr, R. (1997). Events in Austria, European Journal of General Practice, 3: 78.
Glehr, R. (1999). An update from Austria, European Journal of General Practice, 5: 165–166.
Goranov, M.N. and Balaskova, M.I. (1998). General practice in Bulgaria, European Journal of
General Practice, 4: 37–38.
Grol, R. and Wensing, M. (2000). Patients evaluate general/family practice. The Europep
instrument. WOK, University of Nijmegen and Wonca/EQuiP.
Grol, R., Baker, R., Roberts, R. and Booth, B. (1997). Systems for quality improvement
in general practice: A survey in 26 countries, European Journal of General Practice, 3:
65–68.
Improving the quality and performance of primary care 225
Grol, R., Baker, R., Wensing, M. and Jacobs, A. (1994). Quality assurance in general
practice: the state of the art in Europe, Family Practice, 11: 460–467.
Grol, R. (1994). Quality improvement by peer review in primary care: a practical guide,
Quality in Health Care, 3: 147–152.
Grol, R., Wensing, M., Mainz, J. et al. (1999). Patients’ priorities with respect to general
practice care: an international comparison, Family Practice, 16: 4–11.
Gudmundsson, G.H. and Mixa, O. (1998). A report from Iceland, European Journal of
General Practice, 4: 171.
Hearnshaw, H., Baker, R. and Cooper, A. (1998a). A survey of audit activity in general
practice, British Journal of General Practice, 48: 979–981.
Hearnshaw, H., Reddish, S., Peddie, D., Baker, R. and Robertson, N. (1998b). Introducing a
quality improvement programme to primary health care teams, Quality in Health Care
7: 200–208.
Hulscher, M.E.J.L., Wensing, M., Grol., R. et al. (1999). Interventions to improve the
delivery of preventive services in primary care, American Journal of Public Health, 89:
737–746.
Jack, B., Nagy, Z. and Varga, Z. (1997). Health care reform in central and eastern Europe.
Family medicine in Hungary, European Journal of General Practice, 3: 152–8.
Jensen, P.B. (1996). Progress in quality improvement in Denmark, European Journal of
General Practice, 2: 89–90.
Jurgova, E. (1998). The transposition of Slovak health care system and its influence on
primary care services, European Journal of General Practice, 4: 34–36.
Kersnik, J. (1997). Quality improvement in general practice in Slovenia, European Journal
of General Practice, 3: 110–111.
Kuenzi, B. and Egli, N. (1996). Progress from Switzerland, European Journal of General
Practice, 2: 134.
Kvamme, O.J., Olesen, F. and Samuelson, M. (2001). Improving the interface between
primary and secondary care: a statement from the European Working Party on
Quality in Family Practice (EQuiP), Quality in Health Care, 10: 33–39.
Lancaster, T., Silagy, C., Fowler, G. et al. (1998). Training health professionals in smoking
cessation, The Cochrane Library, 4.
Lawrence, M. and Olesen, F. (1997). Indicators of quality in health care, European Journal of
General Practice, 3: 103–108.
Lember, M. (1996). Revaluation of general practice/family medicine in the Estonian
health care system, European Journal of General Practice, 2: 72–73.
Macfarlane, F., Greenhalgh, T., Schofield, T. and Desombre, T. (2004). RCGP Quality Team
Development programme: an illuminative evaluation, Quality and Safety in Health
Care, 13: 356–362.
Makela, M. (1996). Quality assurance in Finnish health care, European Journal of General
Practice, 2: 90–91.
Melander, E., Bjorgell, A., Bjorgell, P., Ovhed, I. and Molstad, S. (1999). Medical audit
changes physicians’ prescribing of antibiotics for respiratory tract infections, Scandinavian Journal of Primary Health Care, 17: 180–184.
Munck, A.P., Gahm-Hansen, B., Sogaard, P. and Sogaard, J. (1999). Long-lasting improvement in general practitioners’ prescribing of antibiotics by means of medical audit,
Scandinavian Journal of Primary Health Care, 17: 185–190.
Munck, A.P., Hansen, D.G., Lindman, A., Ovhed, I., Forre, S. and Torsteinsson, J.B. (1998).
A Nordic collaboration on medical audit, Scandinavian Journal of Primary Health Care,
16: 2–6.
National Primary Care Development Team (2004). National Primary Care Development
Team. Manchester: National Primary Care Development Team (http://www.npdt.
org/, accessed 24 January 2005).
226 Primary care in the driver’s seat
NICE (2002). Principles for Best Practice in Clinical Audit. National Institute for Clinical
Excellence. Abingdon: Radcliffe Medical Press.
Olesen, F. and Jensen, P.B. (1999). A report from Denmark, European Journal of General
Practice, 5: 38.
Persson, L. (1995). Activities in Sweden, European Journal of General Practice, 1: 129.
Persson, L. (1997). A update on quality development in Sweden, European Journal of
General Practice, 3: 77.
Pisco, L. (1997). A report from Portugal, European Journal of General Practice, 3: 32.
Plsek, P. (2001). Redesigning health care with insights from the science of complex adaptive systems. Appendix B in Institute of Medicine, Crossing the Quality Chasm.
Washington, DC: National Academy Press, 309–322.
Polluste, K., Kalda, R. and Lember, M. (2000). Primary health care system in transition: the
patient’s experience, International Journal of Quality in Health Care, 12: 503–509.
Rubin, G., George, A., Chinn, D.J. and Richardson, C. (2003). Errors in general practice
development of an error classification and pilot study of a method for detecting
errors, Quality and Safety in Health Care, 12: 443–447.
Samuelson, M. (1999). A report from France, European Journal of General Practice, 5: 37–8.
Solomon, D.H., Hashimoto, H., Daltroy, L. et al. (1998). Techniques to improve physicians’ use of diagnostic tests. A new conceptual framework, Journal of the American
Medical Association, 280: 2020–2027.
Spies, T.H. and Mokkink, H.G.A. (1999). Toetsen aan standaarden. Het medisch handelen van
huisartsen in de praktijk getoetst. Nijmegen/Utrecht: WOK/NHG.
Thomson, M.A., Oxman, A.D., Davis, D.A. et al. (1998). Outreach visits to improve health
professional practice and health care outcomes, The Cochrane Library, 3.
Tiljak, H. (1998a). Quality assurance in GP/FM in Croatia, European Journal of General
Practice, 4: 88–89.
Tiljak, H. (1998b). An update from Croatia, European Journal of General Practice, 4: 130.
Timmermans, A.E. and In‘t Veld, C.J. (2001). The implementation of guidelines in the
Netherlands, Zeitschrift für Artzliche Fortbildung und Qualitatitsicherung, 95: 719–724.
UEMO (1997). UEMO Statement on Quality Assurance in general practice (UEMO 94/
055), in UEMO. European Union of General Practitioners Reference Book 1996/97, 28–30.
London: Kensington Publications Ltd.
Wensing, M., Van der Weijden, T. and Grol, R. (1998). Implementing guidelines and
innovations in general practice: which interventions are effective? British Journal of
General Practice, 48: 991–997.
Wensing, M., Vedstedt, P., Kersnik, J. et al. (2002). Patient satisfaction with availability of
general practice: an international comparison, International Journal of Quality in Health
Care, 14: 111–118.
Windak, A. (1998). The return of old family doctors in the new Europe, European Journal of
General Practice, 4: 168–170.
Windak, A., Tomasik, T. and Kryj-Radziszewska, E. (1998). The Polish experience of quality
improvement in primary care, Joint Commission Journal on Quality Improvement, 24:
232–239.
Wood, D., De Backer, G., Faergeman, O., Graham, I., Mancia, G. and Pyorala, K. (1999).
Prevention of coronary heart disease in clinical practice, European Journal of General
Practice, 5: 154–161.
Worrall, G., Chaulk, P. and Freake, D. (1997). The effects of clinical practice guidelines on
patient outcomes in primary care: a systematic review, Canadian Medical Association,
156: 1705–1712.
chapter
twelve
The role of new information
and communication
technologies in primary care
Mårten Kvist and Michael Kidd
Introduction
Rapid technological advances have been continuous in medicine over the past
century. In primary care, the impact of new technologies has been variable as
these have often been coopted and harnessed by hospital-based clinicians.
Since the 1960s, however, one domain of technological development has had
rapidly increasing effects on the organization and provision of primary care:
the development and implementation of clinically oriented information and
communication technologies.
This chapter explores the impact of these new information and communication technologies in primary care. It begins by discussing principles of use of
information and communication technology (ICT) and the consequences of its
use in the clinical arena, by distinguishing between the “hard technologies” of
clinical systems, as against the “soft technologies” of clinical practice. Recent
policy debates in the domain of e-health have hypothesized the development of
a “future patient”, who harnesses the developments of the information age and
accesses health care knowledge and practices on a global scale. The truth is
always more mundane, so we begin our analysis by relating the principal “technology” of clinical practice – the structured encounter between clinician and
patient – with the potential range of technological agents that might be brought
into play. The shift to information technologies in primary care runs in parallel
with two wider social shifts in the organization of medicine: one, the shift
towards patient-centred clinical practice, and two, the move towards shared
decision-making. Additionally, coordination of care, over time and across levels
of provision, can also be improved by easier exchange of information, and this
228 Primary care in the driver’s seat
offers new opportunities for continuity of care. This leads to a discussion of
information management tools (a) within the doctor-patient interaction in the
encounter; (b) in providing external input for the benefit of the consultation
within an episode and (c) as a tool in facilitating the coordination of primary care
services across providers/levels of care.
This chapter goes further by discussing the role of electronic records, guidelines and decision support. It analyses the need for hardware and quality of
the telecom infrastructure such as computers, networks and telematics. Professionals (but also patients) need to be prepared for the utilization of ICT and the
consequences for their roles. These subjects are discussed in the section about
education and training. There also will be a need for new legislation to enable
further development without damaging safety and confidentiality of information. This issue is dealt with at the end of the chapter. Finally, some ICTtechnologies are listed, which can provide better patient care when dealt with
appropriately.
ICT and quality and coordination of care
An Australian Government report examined the role of information technology
in quality health care (AHMAC, 1996). This report included the recommendations that:
1. Information is central to improving health care safety and quality. Routine feedback systems are required in order to inform health care workers of the outcomes
of their care and to provide information to health care policy-makers and
consumers in order to drive necessary changes in the health system.
2. There is a mismatch between the use of technology to deliver care to people, and the
use of technology to ensure that the care delivered is safe. Preventable adverse reactions continue to occur despite the best endeavours of clinicians, administrators
and government. Computerized decision support systems offer the potential to
revolutionize safety through the use of alerts and prompts. They can also
improve continuity of care by improving information flows between health care
providers.
3. The use of technology has risks. Not only risks of possible breaches of confidentiality and privacy but also risks of failing to use technology in increasingly
complex health care systems and the risk of potentially preventable injuries and
deaths continuing to occur in health care systems if solutions are not found.
A major area of quality improvement has been in the use of computerized
prescription packages. It has been clearly demonstrated that these can be
used to provide the general practitioner with information about individual
medications, access to clinical guidelines and warnings about potential contraindications, adverse reactions and allergies. Computer generated prescriptions
are legible and accurate. Moreover, the systems allow audits of prescribing for
individual patients and for the practitioner’s patient population.
The role of new information and communication technologies in primary care 229
Quality of health care in general practice also can be improved through the
use of electronic medical management, computerized clinical decision support
systems and improved information flows between general practice and the rest
of the health care system.
The breadth of clinical knowledge necessary for safe, competent and current
primary health care delivery is constantly expanding. Most clinicians now
accept that we cannot carry all the facts we need in our heads. A cultural shift is
evident as clinicians seek current information based on the best available evidence, attempt to access current clinical guidelines and treatment protocols,
and look for answers to clinical questions arising during the consultation.
It is no coincidence that the culture of evidence-based medicine has emerged
at the same time as the information technology revolution and especially at
a time when the world’s information resources have become available to everybody through the Internet. Computers provide possible solutions to many of
the challenges posed by the advocates of evidence-based medicine. They have
the potential to assist in planning the management of patients, in coordination
of their care, in provision of professional continuing education and in the
process of accessing the findings of clinical research. Computer-based assistance
also can help make clinicians more efficient and effective health care providers
if used carefully in the consultation (Purves, 1996). Information technology
thus has the potential to be the cornerstone of the delivery of modern evidencebased primary care.
The role of electronic records, guidelines and decision support
The electronic patient record is a necessary tool for providing patient-centred
and continuing health care safely and efficiently in the modern health care
information environment (Heard et al., 2000). Appropriate utilization of
information about patient contacts in primary health care requires the use of
electronic patient records.
The way in which data are introduced into electronic medical records must be
structured to allow later data retrieval. Different coding systems have been
developed for primary care in different parts of the world. The Read codes are in
use in the United Kingdom. Sweden has developed its own coding system. The
International Classification of Diseases, 10th edition (ICD-10) is used in many
countries even if it is not the most appropriate system for primary health care.
Based on the recognized weaknesses of the ICD system for use in primary
health care, the Classification Committee of WONCA (The World Organization
of Family Doctors) developed a three-dimensional coding system called International Classification of Primary Care (ICPC). The second edition of this coding system, ICPC-2, was published in 1998 and is appropriate for coding reasons
for encounters (RFE) between doctors and patients. The RFE coding can also be
linked to diagnostic procedures, medications, therapeutic procedures and
diagnoses.
The Transhis project in Japan, the Netherlands and Poland has been able to
demonstrate the superiority of this classification for use in primary medical care
(Okkes et al., 2002). ICPC has been accepted as a coding standard in a number of
230 Primary care in the driver’s seat
European countries, including Belgium, Denmark, France, the Netherlands,
Norway, Portugal, and some parts of Finland.
GPs and their patients often express concern about the possible impact of the
use of electronic patient records on the patient-doctor relationship. Is it possible
to maintain as close a relationship when the doctor is often communicating
with a computer during each consultation instead of exclusively paying attention to each individual patient? In practice this should not cause any real problem if each patient is informed about how the information is entered, if the
doctor ensures that adequate time is spent communicating directly with the
patient, and if the patient is engaged as a partner in the process. The use of
computerized records may even increase the trust patients feel in the way
in which such information can be utilized to lead to improvements in their
health care.
One of the key skills which will be required of primary care clinicians will be
the ability to access, assess, select and apply suitable treatment guidelines,
adapted for local circumstances, and to communicate and record variations
in the treatment plan from the guidelines (Coiera, 1998). However, there is a
problem in getting clinical research findings and evidence-based medicine
recommendations into daily clinical practice. One reason for this is that many
clinicians find it difficult to gain rapid and timely access to the systematic
reviews, evidence-based summaries and original scientific reports that may be
relevant to the care of the individual patient in front of them.
Timely computer-based access to relevant knowledge is becoming a reality.
Connection to the Internet means that, as new research findings are made and
guidelines are adapted by learned bodies, the knowledge available to the clinician through the desktop computer could be continuously updated.
Unfortunately there is still a problem with the consolidation of information
into databases of systematic reviews and the preparation of guidelines for
delivery through CD-ROM or web sites (Langley et al., 1998).
Computerized clinical decision support delivered through the computer on
the GP’s desk may however offer a practical solution. It is believed that electronic decision support tools will soon become an increasingly integral component of high quality general practice (Kidd and Mazza, 2000). In the future a
clinical decision support system will be able to compare patient characteristics
with a credible knowledge base and then guide a clinician by offering patientspecific and situation-specific advice. By incorporating evidence-based guidelines, it is believed that the clinical decision-making process can be enhanced,
thereby improving the quality of care.
At present, rudimentary computerized clinical decision support for medication management and preventive care is a reality for many GPs. The most
popular clinical use of computers in general practice in many countries is for
generating prescriptions. Users of computerized prescribing software programs
in some countries will be familiar with systems of prompts for overdue preventive health interventions, and computer-generated cautions about potential
contra-indications, adverse events or allergic reactions in relation to prescribing
decisions (Nolan et al., 1999). In many cases these prompts are based on
elements of clinical practice guidelines for therapeutic management and
preventive care.
The role of new information and communication technologies in primary care 231
Another important area for development and adoption in this field could well
be the use of clinical decision support related to the interpretation of pathology
and radiology test results. In many countries general practices are already
connected online to their pathology providers and receive pathology results
electronically. Soon computerized assistance in the interpretation of diagnostic
results in relation to details in an individual patient’s electronic medical
record could start to take place and advice could be generated through prompts
generated from appropriate clinical guidelines.
Chronic disease management poses a greater challenge. The electronic medical record is currently seen as an essential element in triggering the delivery of
guidelines in chronic and acute disease management. As mentioned earlier
there are impediments to realizing the full potential of the electronic patient
record. In the United Kingdom for example there has been a significant problem
in getting doctors to use the full electronic medical record, although much of
the currently available research relates to past software which often lacked
functionality and speed (Watkins et al., 1999; Ellis and Kidd, 2000).
Whatever happens, the individual style of consultation of many doctors may
well have to change if these features are to be utilized. Many GPs have long been
aware that the computer is becoming somewhat of an imposition in the doctorpatient relationship and that it is impeding the flow of communication (Purves
et al., 1998). This situation will be exacerbated as more time and attention during consultations is paid to information on the computer screen at the expense
of direct communication between doctor and patient.
Another key problem is that most clinical guidelines have not been developed
in a format that allows for easy incorporation into computerized clinical decision support systems. It is not a simple matter of transferring paper-based guidelines into a computerized format (Purves, 1996). The whole process of guideline
development may have to change if we are to match the information provided
by the guideline with the decision-making processes of individual clinicians.
The need for supporting technologies: computers, networks
and telematics
With the rapid evolution of information technology, huge possibilities have
been identified for handling large amounts of data about the health care needs
of populations. An EU working group was established in 1993 to identify how
the applications of telematics to general practice, in the framework of primary
health care, could be further developed in order to improve the quality of health
care in Europe (De Maeseneer and Beolchi, 1994). In the United Kingdom the
government decided in 1989 to start collecting financial data from all practices,
which gave impetus to a rapid increase in the computerization of primary care.
Surveys of general practice computing suggest that over 95% of practices in
the United Kingdom now have computers (Gilles, 2000). The use of those
computers for specific clinical and administrative tasks is much more variable.
In other countries, the use of computers is usually dependent on how primary
care is organized (group practices or solo practices, the existence of a list system
of patients, a national health insurance system, etc.). Even if computers are used
232
Primary care in the driver’s seat
in most practices in a certain country, the extent to which primary care staff use
computers in their everyday work varies.
It is difficult to quantify the current clinical usage of computers in consultations. While some clinicians in a number of countries have full electronic medical records and are moving towards embracing the concept of “The Paperless
Practice” (Ellis, 2001), others use their computers for one or more of a variety of
clinical purposes. These include, among others, word processing reports and
referral letters, electronic prescribing and medication management, decision
support in chronic disease management, recall and prompting about preventive
care interventions, access to electronic information resources, electronic connectivity to pathology and other service providers, and data collection and
reporting to meet government requirements or financial imperatives.
Rates of computer use in primary care consultations also vary significantly
between countries. In the European Survey of the Task Profiles of GPs, it was
found that there was a big variation between 30 European countries in the
percentage (0–74%) of all GPs using computers for patient records (Boerma and
Fleming, 1998). While GPs in countries such as the United Kingdom, the
Netherlands and Scandinavia have been early adopters, many colleagues in
other parts of the world, and especially the United States, are still to adopt
clinical computerization in large numbers. In a European survey on computer
use it was found that there was a correlation between a better structured primary
care system, with patient lists, gatekeeping by the GP, organization in group
practices and higher computer use rate among GPs (Strobbe et al., 1995).
In a study aimed to test the feasibility of deriving comparative quality indicators in 18 practices within a primary care group in the United Kingdom, the
researchers made a retrospective audit using practice computer systems (McColl
et al., 2000). They found that it was possible to derive eight out of 26 indicators
in all practices. It was concluded that practices will need greater conformity and
compatibility of computer systems, improved computer skills for their staff, and
appropriate funding in order to derive indicators.
Connecting computers together in an internal network within a practice creates the opportunity for increased sharing of information about patients
between health professionals. Patient data can be stored as securely as in a paper
archive. Linking computer networks by modems or data transmission using the
Internet further increases the possibilities for sharing patient data with other
health professionals in different locations but of course raises security and privacy concerns. Even the use of e-mails may speed up and increase the efficiency
of many of the GPs’ daily activities. It should be stressed, however that a network only presents a medium, while the content is composed of the messages
transferred within that network (e.g. electronic guidelines). Sometimes these
concepts are mixed, which results in confusion, because related requirements
and obstacles are so different.
Easy access to the Internet can provide the clinician with immediate access to
treatment guidelines, which may, or may not, be kept continuously up to date.
A network in a group practice can provide access to shared CD-ROMs containing
medical information. This may include manuals, evidence-based guidelines,
drug formularies, picture collections of dermatological conditions, etc. Easy
access to such guidelines at the time when they are really needed may improve
The role of new information and communication technologies in primary care 233
clinician compliance with treatment guidelines (Young and Beswick, 1995;
Mäkelä and Kunnamo, 2001).
Efficient use of new communication tools requires a sufficient degree of computerization among other health care providers and organizations. An ideal
system would have all health workers who need to enter patient information
with easy access to a computer preferably located in their immediate working
environment. This may be on the GP’s desktop, or mobile technology to allow
for visits to hospitals and homes. If access is made more troublesome then it is
more likely that information will be handled in more traditional ways. This will
result in computerized records which may lack essential information about
individual patients.
Howcroft and Mitev made an empirical case study in 2000 of Internet usage
and difficulties among medical practice management in the UK. They reported
results from interviews with 37 GPs and as a conclusion they found that the
majority of GPs wanted local electronic links, particularly as regards secondary
care. Given the existing levels of computerization, a surprising number of GPs
failed to use Internet technology and saw little benefit from its use. Some GPs
enthused about technology, while others were positively “techno phobic”.
Non-fundholding general practices in socially deprived areas were far less willing to embrace information management and technology. One explanation
suggested for this is based on priorities: when faced with the option of ‘cruising’
the information superhighway, as opposed to treating seriously ill patients
living in socially deprived areas, the former may simply be relegated as less
important.
Telemedicine is by definition a science focused on the transmission of health
information in an electronic network, but practically it has been focused on
problems with transmission of both still and live pictures. When cameras are
connected to computers, digital images can easily be transferred over the existing network to other destinations and be retrieved with the same quality as they
were recorded. X-ray pictures have been transferred between hospitals and radiologists for more than 35 years. The same technique can also be used in primary
care settings which have X-ray facilities but no consultant radiologist on site.
There are considerable investments required in the essential infrastructure, and
needs should be carefully assessed before purchasing expensive technology.
Accumulated experience from those centres which have introduced telemedicine technology reveals that in more than 50% of cases telemedicine has been
used for educational purposes (Wootton, 2001). Time and travel costs can be
saved for health professionals but increased efforts are needed in preparing for
educational events mediated as videoconferences. In some instances the transmission of live pictures can be slow and the pictures distorted. This problem can
be eliminated by using rapid data transmission lines.
Since 1995, Queen’s University, Northern Ireland, has organized real-time
teledermatology consultations using videoconferencing for a number of primary
health care institutions and the results have been impressive (Loane, 1999). This
example has later been followed by others, for example in Nottingham (Lawton
et al., 2004).
All disciplines where images play an important role in the diagnostic process
can use telemedicine. When the video-cable is moved from a camera to a
234 Primary care in the driver’s seat
microscope or to endoscopic equipment, live pictures can easily be transmitted
from the general practice to a consultant located far away. Over the last
decade there have been developments in teleradiology, teledermatology, telepathology, teleorthopaedics, telesurgery and teleophthalmology (Kvist, 1996;
Lamminen and Nevalainen, 1999; Gonzales et al., 2001). Telepsychiatry is a field
with huge opportunities and good results have been demonstrated in many
studies (Mielonen et al., 1998; Gammon, 1999).
Studies on the interpretation differences between radiologists assessing real
film pictures and screen pictures, scanned and transferred to remote sites and
assessed on a computer screen, have shown good correlation (Krupinski et al.,
1996). Theoretically, if the pictures are taken initially with digitized X-ray
equipment there should be no difference in quality as the identical information
is available at the remote site. The trend is toward digitized X-ray equipment
where no film is actually needed. However, the high cost of such equipment
will still result in normal X-ray equipment as a required alternative for group
practices of limited size.
In Finland the first demonstration of telegastroscopy was performed in 1995
with the consulting physician 900 kilometres away from the patient, providing
immediate feedback about the status of the gastric mucosa and the best location
for a possible biopsy (Kvist, 1995). In cases where gastroscopies are performed by
clinicians with insufficient experience (less than 100–300 procedures), the
addition of a telemedicine consultation with a more experienced clinician, or
training with an endoscopic simulator, can make this a more reliable method of
investigation (Bar-Meir, 2001).
All endoscopies are examples illustrating where telemedicine may add value
to procedures performed in primary care. Experiments with distance ultrasound
diagnostics of the upper abdomen have shown that it is possible to use it for
these purposes too (Kormano, 1995). In a pilot study in northern Norway a GP
was provided with the necessary equipment to carry out otorhinolaryngological
consultations using telemedicine connections. This clinician’s skills have
increased and many patients have avoided the need to travel 700 km to the
nearest university clinic (Pedersen et al., 1999).
The cost-effectiveness of telemedicine services still needs to be fully evaluated.
Taking into account the necessary investments in new technology it appears
that for regular clinical use there may be little, if any, savings of health care
resources. However, patients may benefit from significant savings in travel time
to specialists or reduction in delays between the initial presentation of symptoms and the time when a correct diagnosis can be made and appropriate
treatment initiated.
The Internet has arrived at the same time as health consumers are starting to
seriously question the traditional doctor-patient relationship and to play a
greater role in the management of their own health care (Jadad, 1999; Eysenback,
2000). If GPs are to continue to be the trusted cornerstone of health care delivery in each of our countries, they will need to start to adapt to the changing
expectations of their patients and the use of the Internet by patients as a tool
for health care.
Internet visionary Nicholas Negroponte wrote: ‘On the Internet, no-one need
know you’re a dog’ (Negroponte, 1995). Anyone can establish a web site on a
The role of new information and communication technologies in primary care 235
health related topic and claim to be an expert. The Internet is littered with
potentially dangerous sites, and patients need to be wary of all information
gained through it. As do their GPs. It is up to each individual to make a judgement about the quality of a site. One needs to scrutinize the source of the information. ‘Can I trust the information on this site? Can I trust the author? Do their
qualifications and affiliations sound genuine? Is this information current?’
Many consumer groups and medical organizations and professional bodies
offer links to sites which they have evaluated and believe will be of benefit to
their members and other visitors to their own home pages. There may well be a
place for the home page of each general practice to become the portal to useful
and validated information on the Internet, specifically chosen for their patient
population. One online survey showed that 50% of respondents would be
interested in using a web site operated by their own doctor’s office (Pyke, 1999).
One of the more recent challenges for GPs is the patient who presents with
information gained from a search of the Internet. This seems to be particularly
relevant for people with chronic health problems who may have a degree of
dissatisfaction with some aspect of their current health care management. One
approach is to try to determine what has motivated this person to bring in this
information, and what concerns led to this fact-finding mission (Kidd, 2001).
It is also becoming apparent that many patients would like to communicate
with their doctors online. Cyberconsultations, consulting with patients through
e-mail or the Internet, represent a challenge to traditional methods of clinical
care delivery. E-mail could be used by patients to request the results of pathology and radiology tests, to request repeat prescriptions or letters of referral, or
to ask questions which arise after a consultation has ended.
E-mail communication does, however, carry some risks. Just as GPs have
developed methods for handling telephone-based consultations with patients,
they will also have to develop ways of handling requests for information
received via the Internet. There are risks to the security of personalized health
information sent by e-mail. There are risks if patients misinterpret information
provided to them by e-mail. There are risks that doctors will end up with a large
volume of unpaid extra computer work.
This poses additional challenges to the doctor-patient relationship. Each
e-mail message to a patient becomes a legal document. It is possible that e-mail,
through the creation of a “virtual relationship” which did not previously exist,
could create a duty of care relationship where the doctor did not intend to create
one. It is possible that doctors could find themselves with increased responsibility to respond to enquiries that they might otherwise have not been able to
receive. Delays in response may bring added risks for patients (Kidd et al., 2002).
However, these developments may also revolutionize health care delivery. In
the place of discrete episodic visits to the doctor, contact and management
advice may be able to be delivered in a continuous and ongoing manner. This
could become a powerful clinical tool with the added ability for home
monitoring and Internet-based transmission of vital signs and home pathology
results. The role of the GP could become even more central in the management
of many chronic health care problems. True continuity of care could become a
reality as the GP’s computer system allows the doctor to keep track of the care of
individual patients on a daily basis.
236 Primary care in the driver’s seat
For health care managers a new technology has recently been made available
on Internet for managers of Primary Care Trusts. Web-based interactive maps of
PCT star ratings are accessible for all managers, who want to compare the performance of their trust with the corresponding results of other trusts. By acting
as an enhanced alternative or supplement to purely textual online interfaces,
interactive web maps can further empower organizations and decision-makers
(Boulos, 2004).
Education and training
Education and training of the clinical workforce are essential if new technologies are to be successfully incorporated in general practice and have an impact
on clinical care. Many authors have addressed the need to include training
about information technology in clinical education programmes and have outlined ways of educating health care workers and students on how to use information technology in their daily clinical practice (Hardy et al., 1996; Carlile
and Sefton, 1998; Lawson et al., 1998; Kidd and McPhee, 1999). Unfortunately
many health care professionals find that current education about the use of
computers in health care can be dry and not very appealing, especially if the
emphasis is on the technology, rather than its applications in clinical care.
Working through clinical scenarios and identifying the information issues and
their personal implications for learners can be far more effective education
strategies (National Health Service, 1997). However, education solely about
basic computer use is not sufficient for health care professionals. Clinicians also
need to be equipped with advanced skills in information management if they
are going to be able to meet the challenges of evidence-based medicine, provide
truly coordinated care and tackle the problems associated with information
overload.
It has been argued that education about information technology for health
care workers requires a three-pronged approach (Koschmann, 1995). Clinicians
need to learn about computers (i.e. their potential applications in health care).
They need to learn through computers (i.e. how to use the technology to receive
continuing education). Most powerfully, they need to learn with computers (i.e.
through using this technology as part of their daily work, and through using its
features to assist them to identify and meet their educational needs while
working).
The National Health Service in the United Kingdom has produced recommendations for health informatics training in the education of their clinicians
(National Health Service, 1999). These recommendations identify common
elements across clinical practice relevant to all health care workers and provide
advice on education strategies. The eight elements addressed are communication, knowledge management, data quality and management, confidentiality
and security, secondary uses of clinical data and information, clinical and service audit, working clinical systems and telemedicine and telecare. The recommendations also provide a list of ten basic computing skills that are required by
all health care professionals (Figure 12.1)
A more clinically targeted list of essential clinical informatics skills (Coiera,
The role of new information and communication technologies in primary care 237
Figure 12.1 Ten basic computing skills for health care professionals
1. Organize electronic information (e.g. naming documents, setting up
directories, moving files, renaming files);
2. Use a word-processing package to generate simple documents;
3. Enter and manipulate data using a spreadsheet;
4. Search a simple database;
5. Undertake searches and access relevant sites on the World Wide Web
and relevant health-related databases;
6. Retrieve/download electronic documents from various sources and
transfer data from one application to another;
7. Explain the reasons for electronic networking and give examples of its
use in health care;
8. Send, retrieve and acknowledge e-mails and attachments;
9. Identify examples of the use of information technology as an effective
tool in the delivery and management of health care;
10. Evaluate the effective use of information systems in the National
Health Service. Discuss why different examples should be paper-based
or electronic.
Source: National Health Service (1999).
1998) has been recommended for health care professionals in Australia
(Figure 12.2).
Together these recommendations can form the basis for an informatics education curriculum for GPs and other primary health care workers.
Legal aspects and data safety
The introduction of new technology can also face barriers when conflicts arise
with existing legislation in individual countries. In some cases legislation has
not foreseen or kept up to date with the developments taking place in clinical
care. A transfer to completely paper-free records may not be legally possible
without revision of existing legislation in some countries. The same rules apply
to the storage of X-ray images. The data of these huge picture files may cause
problems and necessitate new approaches to archiving. While technical solutions are often available, considerable investment may also often be required. A
requirement of health authorities is that, from a legal point of view, it should be
possible to audit all changes which have been made to original records both by
date, content and provider. There are technical solutions to these problems.
New ways of interacting with patients using telemedicine or through the
Internet can pose other legislative challenges. These new consultations can
transcend traditional geographic boundaries and it is possible to consult with
patients in other parts of the same country or across international borders.
These innovations do not sit easily where legal and regulatory systems are often
238 Primary care in the driver’s seat
Figure 12.2 Ten essential clinical informatics skills
1. Understand the dynamic and uncertain nature of medical knowledge,
and be able to keep personal knowledge and skills up to date;
2. Know how to search for and assess knowledge according to the
statistical basis of scientific evidence;
3. Understand some of the logical and statistical models of the diagnostic
process;
4. Interpret uncertain clinical data and deal with artefact and error;
5. Structure and analyse clinical decisions in terms of risks and benefits;
6. Apply and adapt clinical knowledge to the individual circumstances
of patients;
7. Access, assess, select and apply a treatment guideline, adapt it to local
circumstances, and communicate and record variations in treatment
plans and outcome;
8. Structure and record clinical data in a form appropriate for the
immediate clinical task, for communication with colleagues, or for
epidemiological purposes;
9. Select and operate the most appropriate communication method for a
given task (e.g. face-to-face conversation, telephone, e-mail, video,
voice-mail, letter);
10. Structure and communicate messages in a manner most suited to the
recipient, task and chosen communication medium.
Source: Coiera (1998).
very ‘jurisdiction-specific’, and it is assumed that clinical service delivery has
taken place in the ‘traditional’ face-to-face manner.
It is apparent that the introduction of ICT systems can ‘raise the bar’ of
expectations, especially around privacy, security and confidentiality of personal
health information. There are, as yet, few established legal principles, but the
application of ‘first principles’ will give some preliminary guidance. These principles demonstrate that ‘the bottom line’ is whether or not a professional has
exercised ‘reasonable’ care. The computer is likely to be regarded as a tool. Like
all other tools, professionals who choose to use ICT will be expected to know
how to use such tools safely.
GPs may find themselves legally exposed if they rely on an electronic clinical
decision support tool that ‘leads them astray’. It is possible that patient harm
could be caused by the use of high technology tools. In such an event, users
may complain that the technology was faulty, misleading or confusing. The
manufacturer could respond that user error was to blame.
Conversely clinicians may – in the not too distant future – find themselves
legally exposed if they fail to use appropriate electronic clinical decision support
tools and computerized patient record systems. Community and legal expectations are likely to change as technology becomes more widespread and
accepted as ‘best’ clinical practice. Clinicians may find themselves being
The role of new information and communication technologies in primary care 239
criticized if they turn off decision support tools with drug-drug interaction
information, or if they fail to access best practice guidelines known to be
available on the Internet (Milstein and Togno, 2001).
The reorganization of the NHS in England into 303 Primary Care Trusts
in 2002 increased expectations, that they could be powerful agents for change
in a more devolved, clinically driven and locally responsive NHS. There is, however, a growing belief that these trusts have failed to fulfil these expectations,
and that the organizations are perhaps ineffective. Further reorganization
would reduce the number of primary care trusts to about 100–150 across
England. Thus, the organizational restructuring seems to promote a change
back towards the size of the original units, from which the trusts were originally
created. The wave-like change of organizational structures has stressed the
importance of well-functioning communication technology in public health
networks, but there is no definitive evidence that structural reorganization of
Primary Care Trusts would be of benefit to patients (Fahey et al., 2003; Walshe
et al., 2004).
Conclusions
ICT offer good opportunities to further develop a coordinative role in
primary health care. The use of new information and telecommunication
technologies within the primary care consultation may extend its reach and
make its boundaries more permeable. The widespread use of e-mail and
the Internet by “information literate” patients may reshape doctor-patient
interaction, but it brings in its wake problems of quality control relating to
information, and of licensing and liability. If the boundaries of doctor-patient
interaction are made permeable by the Internet and e-mail, they are also
reshaped by new communications systems within health care organizations
themselves, in particular telemedicine. These technologies do not simply
change the procedures by which information moves through health care systems, but they also impact upon the professional identities of the clinicians that
use them.
The proliferation and expansion of new technologies in primary health care
draws into view not only a “future patient”, but also a “future clinician”. New
technologies confront clinicians with new ethical questions about safety and
liability, privacy and evidence, and the globalization of medical knowledge
and clinical practice. We are moving toward an ICT-based practice with special
conditions and requirements.
As clinical computer use in general practice becomes more widespread, evidence of the quality benefits is being accumulated. Systematic reviews of trials
on the effects of computer-based clinical decision support systems on physician
performance have been shown to improve antibiotic prescribing, drug dosing,
preventive care and other aspects of primary medical care (Sullivan and Mitchell,
1995; Balas et al., 1996; Pestonik et al., 1996; Baker, 1997; Beilby and Silagy,
1997; Hunt et al., 1998; Mitchell and Sullivan, 2001). Good knowledge of these
opportunities offered by the ICT technology, are necessary if the future GP is
going to be in the primary care driver’s seat.
240 Primary care in the driver’s seat
Conditions for an ICT-based primary care are:
• continuity of care/patient and doctor knowing each other;
• practice organization/scale of practice;
• financing/insurance system;
• cooperation between primary and secondary care;
• staff skills;
• compatible systems/software in own language/availability
•
•
•
•
of coding and
classification systems;
legislation;
infrastructure;
well-developed professional infrastructure (CME, guideline production);
informed patients.
References
AHMAC (Australian Health Ministers’ Advisory Council) (1996) Taskforce on Quality in
Australian Health Care of the Australian Health. Canberra: Department of Health and
Aged Care, Australia.
Baker, R. (1997). Review: computerized reminders increase the rate of use of most
preventive services, ACP Journal Club 126(3): 80.
Balas, E.A., Austin, S.M., Mitchell, J.A., Ewigman, B.G., Bopp, K.D., Brown, G.D. (1996).
The clinical value of computerized information services: a review of 98 randomized
clinical trials, Archives of Family Medicine 5(5): 271–278.
Bar-Meir, S. (2001). Training models – why and how, in Poster Abstracts from the Falk
Symposium on Medical Imaging in Gastroenterology and Hepatology, in Hannover,
Germany, 28–29.9, 19. www.falkfoundation.com/pdf/FS124-Internet.pdf.
Beilby, J.J. and Silagy, C.A. (1997). Trials of providing costing information to general
practitioners: a systematic review, Medical Journal of Australia 167(2): 89–92.
Boerma, W.G.W. and Fleming, D.M. (1998). The Role of General Practice in Primary Health
Care. London: World Health Organization.
Boulos, K.M.N. (2004). Web GIS in practice: an interactive geographical interface to
English Primary Care Trust performance ratings for 2003 and 2004, International
Journal of Health Geographics 3(1): 16.
Carlile, S. and Sefton, A.J. (1998). Healthcare and the information age: implications for
medical education, Medical Journal of Australia 168: 340–343.
Coiera, E. (1998). Medical informatics meets medical education, Medical Journal of Australia
168: 319–320.
De Maeseneer, J. and Boelchi, L. (1994). Telematics in primary health care: a concerted
action (AIM-PRIMACARE A 2015), Computer Methods and Programs in Biomedicine 45:
145–147.
Ellis, N. (2001). Going Paperless: A Guide to Computerisation in Primary Care. Abingdon:
Radcliffe Medical Press.
Ellis, N. and Kidd, M.R. (2000). What lessons can Australia learn from the computerisation
of General Practice in the United Kingdom? Medical Journal of Australia 172: 22–24.
Eysenback, G. (2000). Consumer health informatics, British Medical Journal
320: 1713–1716.
Fahey, D.K., Carson, E.R., Cramp, D.G. and Muir Gray, J.A. (2003). User requirements and
understanding of public health networks in England, Journal of Epidemiology and
Community Health 57(12): 938–944.
The role of new information and communication technologies in primary care 241
Gammon, D. (1999). Telepsychiatry in Norway, in Wootton, R. (ed.) European Telemedicine
1998/1999. London: Kensington Publications Ltd, 89–90.
Gilles, A. (2000). Information support for general practice in the new NHS, Health Libraries
Review 17: 91–96.
Gonzales, F., Iglesias, R., Suarez, A., Gomez-Ulla, F. and Perz, R. (2001). Teleophtalmology
link between primary health care centre and a reference hospital, Med Inform Internet
Med 26(4): 251–263.
Hardy, J.L., Conrick, M., Foster, J., McGuiness, B. and Bostock, E. (1996). Computerised
education for health professionals, in Hovenga, E., Kidd, M. and Cesnik, B. (eds),
Health Informatics: An Overview. Melbourne: Churchill Livingstone.
Heard, S., Givel, T., Schloeffel, P. and Doust, J. (2000). The benefits and difficulties of
introducing a national approach to electronic health records in Australia. Report to
the electronic health records taskforce. Adelaide: Commonwealth Department of
Health and Aged Care.
Howcroft, D. and Mitev, N. (2000). An empirical study of Internet usage and difficulties
among medical practice management in the UK, Internet Research: Electronic Networking Applications and Policy 10: 170–181.
Hunt, D.L., Haynes, R.B., Hanna, S.E. and Smith, K. (1998). Effects of computer-based
clinical decision support systems on physician performance and patient outcomes – a
systematic review, Journal of the American Medical Association, 280(15): 1339–1346.
Jadad, A.R. (1999). Promoting partnerships: challenges for the internet age, British Medical
Journal, 319: 761–764.
Kidd, M.R. (2001). General practice and consumers on the Internet, Australian Family
Physician 4 .
Kidd, M.R. and Mazza, D. (2000). Clinical practice guidelines and the computer on your
desk, Medical Journal of Australia 173: 373–375.
Kidd, M.R. and McPhee, W. (1999). The “Lost Generation”: IT education for healthcare
professionals, Medical Journal of Australia 171: 510–511.
Kidd, M.R., Milstein, B. and Togno, J. (2002). The computer on your desk: new roles, new
rules and new challenges for general practice, New Zealand Family Physician 29(4):
226–228.
(http://www.rnzcgp.org.nz/NZFP/Issues/Aug2002/Kidd-August-02.pdf,
accessed 17 February 2004).
Kormano, M. (1995). Presentation at the National Conference in Telemedicine, Turku,
Finland, 24–25 October.
Koschmann, T. (1995). Medical education and computer literacy: learning about, through,
and with computers, Academic Medicine, 70(9): 818–821.
Krupinski, E.A., Weinstein, R.S. and Rozek, L.S. (1996). Experience-related differences
in diagnosis from medical images displayed on monitors, Telemedicine Journal 2:
101–108.
Kvist, M. (1995). Telemedicine. Presentation at the Annual Medical Conference, Helsinki,
Finland, 11 January.
Kvist, M. (1996). Telemedicine applications in Finland 1996. Helsinki: National Agency
for Welfare and Health; FinOHTA publication No 2. (http://www.stakes.fi/finohta/e/
reports/002/r002f.html, accessed 17 February 2004).
Lamminen, H. and Nevalainen, J. (1999). Telemedicine in orthopaedics, in Wootton, R.
(ed.) European Telemedicine 1998/1999. London: Kensington Publications Ltd, 93–96.
Langley, C., Faulkner, A., Watkins, C., Gray, S., and Harvey, I. (1998). Use of guidelines in
primary care – practitioners’ perspectives, Family Practice 15: 105–111.
Lawson, K., Armstrong, R. and Van der Weyden, M. (1998). A sea change in Australian
medical education, Medical Journal of Australia 169: 653–658.
Lawton, S., English, J., McWilliam, J., Wildgust, L. and Patel, R. (2004). Development of a
district-wide teledermatology service, Nursing Times 100(14): 38–41.
242 Primary care in the driver’s seat
Loane, M. (1999). Real/time dermatology, in Wootton, R. (ed.) European Telemedicine 1998/
1999. London: Kensington Publications Ltd, 76–78.
Mäkelä, M. and Kunnamo, I. (2001). Implementing evidence in Finnish primary care. Use
of electronic guidelines in daily practice, Scandinavian Journal of Primary Health Care
19(4): 214–217.
McColl, A., Roderick, P. and Smith, H. et al. (2000). Clinical governance in primary care
groups: the feasibility of deriving evidence-based performance indicators, Quality in
Health Care 9: 90–97.
Mielonen, M-L., Ohinmaa, A., Moring, J. and Isohanni, M. (1998). The use of videoconferencing for telepsychiatry in Finland, Journal of Telemedicine and Telecare 4: 125–131.
Milstein, B. and Togno, J. (2001). Legal Issues in General Practice Computerisation. Barton:
General Practice Computing Group. (http://www.gpcg.org/publications/docs/
projects2001/GPCG_Project22_01.pdf, accessed 17 February 2004).
Mitchell, E., and Sullivan, F. (2001). A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980–97, British
Medical Journal 322: 279–282.
National Health Service (1997). Approaches for informatics in postgraduate medical and dental
education: an account from four national pilot sites. National Health Service Education and
Training Program in Information Management and Technology for Clinicians. London:
NHS.
National Health Service (1999). Learning to Manage Health Information. Bristol: National
Health Service Executive.
Negroponte, N. (1995). Being Digital. New York: Knopf.
Nolan, A., Norquay, C., Dartnell, J., and Harvey, K. (1999). Electronic prescribing and
computer-assisted decision support systems, Medical Journal of Australia 171(10):
541–543.
Okkes, I.M., Polderman, G.O., Fryer, G.E. et al. (2002). The role of family practice in
different health care systems: a comparison of reasons for encounter, diagnoses, and
interventions in primary care populations in the Netherlands, Japan, Poland, and the
United States, The Journal of Family Practice 51: 72. (www.jfponline.com/content/
2002/01/jfp_0102_00072.asp, accessed 17 February 2002).
Pedersen, S., Haga, D. and Arild, E. (1999). Tele-otorhinolaryngology (tele-ENT), in
Wootton, R. (ed.) European Telemedicine 1998/1999. London: Kensington Publications
Ltd.
Pestonik, S.L., Classen, D.C., Scott Evans, R. and Burke, J.P. (1996). Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and
financial outcomes, Annals of Internal Medicine 124(10): 884–890.
Purves, I. (1996). Facing future challenges in general practice: a clinical method with
computer support, Family Practice 13(6): 536–543.
Purves, I., Nestor, G. and Williams, K. (1998). Testing of PRODIGY continues, British
Medical Journal 316: 776.
Pyke, B. (1999). The rise of the Internet health consumer: impacts of the Internet on the
doctor-patient relationship. (http://www.cyberdialogue.com/pdfs/wp/wp-cch-1999doctors.pdf, accessed 19 February 2004).
Strobbe, J., De Maeseneer, J. and Ceenaeme, R. (1995). A picture of primary health care in
Europe, in de Maeseneer, J. and Beolchi, L. (eds) Telematics in Primary Care in Europe.
Amsterdam: IOS Press.
Sullivan, F. and Mitchell, E. (1995). Has general practitioner computing made a difference
to patient care? A systematic review of published reports, General Practice 311:
848–852.
Walshe, K., Smith, J., Dixon, J. et al. (2004). Primary care trusts. Premature reorganisation,
with mergers, may be harmful, British Medical Journal, 329: 871–872.
The role of new information and communication technologies in primary care 243
Watkins, C., Harvey, I., Langley, C., Gray, S. and Faulkner, A. (1999). General practitioners’ use of guidelines in the consultation and their attitudes to them, British
Journal of General Practice 49: 11–15.
Wootton, R. (2001). Recent advances: telemedicine, British Medical Journal 323: 557–560.
Young, A. and Beswick, K. (1995). Protocols used by UK general practitioners, what is
expected of them and what solutions are provided, Computer Methods and Programs in
Biomedicine 48: 85–90.
Key references for further reading
1.
2.
3.
4.
5.
6.
7.
www.globalfamilydoctor.com (web site of WONCA, The World Organization of
Family Doctors, featuring links to many useful resources for primary medical care
providers).
www.gpcg.org (web site of the General Practice Computing Group, the peak national
organization for primary medical care computing in Australia, featuring resources
targeted to the needs of general practitioners involved in the computerization of the
consultation).
www.imia.org (web site of the International Medical Informatics Association with
links to resources which promote informatics in health care and biomedical research).
www.phcsg.org.uk (web site of The Primary Health Care Specialist Group of the
British Computer Society with a link to The Journal of Primary Care Informatics).
www.amia.org (web site of the American Medical Informatics Association with links
to The Journal of the American Medical Informatics Association, a peer-reviewed
journal published bimonthly containing articles about all aspects of medical
informatics).
www.fimnet.fi/telemedicine/index2.html (web site of the Finnish Society of
Telemedicine with useful links to telemedicine web sites).
www.americantelemed.org (web site of the American Telemedicine Association).
Acknowledgements
This chapter draws on the following previous publications of the authors:
Kidd, M.R. (2001). General practice and consumers on the Internet, Australian Family
Physician 4.
Kidd, M.R., Milstein, B. and Togno, J. (2002). The computer on your desk: new roles, new
rules and new challenges for general practice. New Zealand Family Physician 29(4):
226–228 (http://www.rnzcgp.org.nz/NZFP/Issues/Aug2002/Kidd-August-02.pdf,
accessed 17 February 2004).
Kidd, M.R. and Mazza, D. (2000). Clinical practice guidelines and the computer on your
desk, Medical Journal of Australia 173: 373–375.
Kidd, M.R. and McPhee, W. (1999). The “Lost Generation”: IT education for healthcare
professionals, Medical Journal of Australia 171: 510–511.
Kvist, M. (1991). Telephone contacts in Finnish urban general practice [Dissertation].
Turku University Publication, series D, No. 71, Turku.
Kvist, M. (1996). Telemedicine applications in Finland 1996. Helsinki: National Agency
for Welfare and Health, 1996; FinOHTA publication No. 2 (http://www.stakes.fi/
finohta/e/reports/002/r002f.html, accessed 15 March 2004).
Index
Page numbers in italics refer to tables; in chapter 2 the location of figures is indicated by
cross references in the relevant text.
access to care, 64
payment system effects, 193–4
skill mix changes, 158
access to evidence, role of ICT, 230
accession countries (EU), payment systems,
190
accomplishments of primary care, 74–6
accountability, culture of, 58–60
accreditation/reaccreditation
lifelong learning cycle, 178–80
objectives, methods and responsible bodies,
174–7
political aspects, 177–8
practice certification, Germany, 211
see also continuing medical education
(CME); quality improvement, national
policies
advisors, specialist, 157
anticipatory and preventative medicine, 4–5
audit, 210–11
Austria
payment system, 189
quality improvement policies, 215
Baker, R., 58–9, 204
et al., 221
and Grol, R., 204
Belgium
payment system, 189
quality improvement policies, 215
Beveridge system see tax funded model
Bismarck system see social health insurance
model (SHI)
Boema, W.G.W., 6, 9, 40, 56, 68, 150
et al., 9, 34, 68
and Fleming, D.M., 9, 14, 15, 16, 34, 40, 63,
68, 75, 171, 192
budgets, devolved see purchasing
Calnan, M., 70
et al., 9, 35, 100
Groenewegen, P.P. and, 185
capitation payment system, 192
effects, 185–6, 193, 194, 195
funding, 191
integrated, 186, 191
policy conclusions, 195–6
Catalonia see under Spain
central and eastern European countries
(CEECs)
education and training, 152, 171, 173
Primary Health Care (PHC) settings, 89–90,
93–4, 129
quality improvement policies, 217–18
246 Primary care in the driver’s seat?
reforms, 133, 143
see also Soviet model (Semashko system);
specific countries
changes in primary care, 70–4
see also reforms
chronic disease management
nurse management, 153–4
role of ICT, 231, 235
service transfer (diabetes), 156
clinical audit, 210–11
clinical decision support, role of ICT, 230, 231
clinical governance, 58–9
see also governance
clinical guidelines see guidelines
coding systems, electronic records, 229–30
commissioning of services
UK, 98–9, 109, 110
see also purchasing
communication problems, 87–8
community psychiatric nurses, 9
community services purchasing, Finland, 113
competence, 65
competition and contestability, publicprivate mix, 135–7, 144
complexity, 4
compliance
guaranteeing, 51
with recertification, 178
comprehensiveness see generalism and
comprehensiveness
computer(s), 64
skills, 237
use in practices, 231–2
see also information and communication
technologies (ICT)
consumer choice, 196
continuing challenges for primary care, 76
continuing medical education (CME)
institutions providing, 166, 168
and quality improvement reviews, 208
in reform agenda, 53, 59, 62–3, 65
see also accreditation/reaccreditation
continuing professional development, 59
continuity of care, 12–13, 62, 64–5
challenge in UK, 100
comparisons across Europe, 39, 41, 44–5
contracts, 106–7, 136
coordination, 13–14
aspects of challenge, 70
cost-effectiveness, 15
driver’s seat question, 78–80
organizational decision-making as, 51
problems, 85–6
manifested in health systems, 86–90
solutions in health systems, 90–100
requirements for, 61–5
role of ICT, 228–31
see also network coordination; teamwork
cost
impact of payment systems on, 194–5
of recertification, 177–8
cost-effectiveness
coordination, 15
purchasing, 116
counsellors, 157
CME see continuing medical education
credibility question, 78
Croatia
coordination solutions, 93–4
quality improvement policies, 217
Czech Republic, quality improvement
policies, 218
data
on resources, 28
safety, 237–9
decentralization, 53, 55
decision-making
clinical, role of ICT, 230, 231
organizational, 51
delegation (senior to junior staff), 154–5
payment system effects, 193
Denmark
payment system, 189
quality improvement policies, 213
density, GP, 29, 30
diabetes management, 156
diagnostic facilities, 39–40, 46
diagnostic processes, role of ICT, 231, 233–4
disciplines (other than GPs), 9–10, 63
involved in home care, 31–2
Dixon, A.
et al., 25
and Mossialos, E., 25, 56
doctor-patient relationship, impact of ICT,
230, 231, 235
Donabedian, A., 204
Donaldson, J.S. et al., 7
driver’s seat question, 78–80
e-mail consultations, 235
economic dimension in health systems, 25
education
development of, 170–1
governance models, 169
main actors and stages in, 165–8
specialist, 172, 173
specialist liaison, 157
undergraduate, 171–2
in use of ICT, 236–9
see also accreditation/reaccreditation;
continuing medical education (CME)
effectiveness
of quality improvement methods, 206–11
of skill mix changes, 158–9
see also cost-effectiveness
electronic records, 229–30, 231
emergency care, Netherlands, 94–5
employment mode see payment systems
enhancement of roles, 153–4
equity, impact of purchasing on, 118
Estonia
Index
purchasing, 114
quality improvement policies, 218
EURACT, 165–6, 168, 169, 172
European quality improvement standards,
219–20
European Union
governance models, 169
international organizations, 169–70
payment systems, 189–90
European Union of General Practitioners
(EUMO), 170, 206
evidence-based medicine, role of ICT, 229
family medicine see general practice
fee-for-service system, 192
effects, 185, 193–4, 194–5
funding, 191
policy conclusions, 195
financial issues
incentives see income; payment systems
resources, 28–9
responsibility for networks, 77
risks in purchasing, 117–18, 120–1
substituting private for public provision,
137
see also cost; cost-effectiveness; funding
models
Finland
networks of cooperation, 125
payment system, 189
Primary Care Act, 74, 75
primary care centre (vignette), 22–5
purchasing, 112–14, 119, 120, 122, 124
quality improvement policies, 213
telemedicine, 234
first contact care, 35, 42–3, 62
Fleming, D.M., 196
see also Boema, W.G.W.
flexible service provision, purchasing, 116
former Soviet Union
Russian Federation, 112, 120–1
see also central and eastern European
countries (CEECs); specific countries
former Yugoslavia
medical cooperatives in, 138
see also central and eastern European
countries (CEECs); specific countries
France, 57
coordination issues, 88, 90–2
payment system, 189
quality improvement policies, 215–16
fundholding GPs, UK, 97, 108, 135, 191
funding models, 25, 55–6
home nursing, 32–3
see also health systems; specific
models/countries
gatekeeping, 41
and consumer choice, 196
problems, 87–8
role, 87, 99–100
247
vs. non-gatekeeping systems, 88–90
general practice, 7–9
comparisons across Europe, 34–41, 42–6
general practitioners see entries beginning GP
generalism and comprehensiveness, 35–6,
42–3
Germany, 57
integrated care structures, 140
payment system, 188, 189
practice networks, 141
quality improvement, 208, 211, 216
university polyclinics, 135
governance
by network coordination, 52–4
clinical, 58–9
education, models of, 169
and funding models, 55–7
impact of purchasing, 118
mechanisms of, 51–2
mixes of, 55–6
types of, 51, 55
GP commissioning groups, UK, 109
GP density, 29, 30
GP fundholders, UK, 97, 108, 135, 191
GP income, 29–30
GP job satisfaction, 40, 46
GP partnerships/groups, 52–3, 132
HAGROs, Netherlands, 94
size, 149, 150
UK, 132
see also medical cooperatives; Primary Care
Groups (PCGs)/Trusts (PCTs), UK
GP pension schemes, 143
GP role enhancement, 154
GP status, 16–17
GP wards, Netherlands, 96
GP workload, 88
Greece, payment system, 189
Groenewegen, P.P.
and Calnan, M., 185
et al., 51, 52, 60
Grol, R., 54, 207, 212
Baker, R. and, 204
et al., 204, 206, 211, 220
and Grimshaw, J., 54
guidelines, 53–4, 209–10
role of ICT, 230, 231
health care managers, use of ICT, 236
health informatics
skills, 238
training, UK, 236
health systems
coordination issues, 86–100
economic and political dimensions, 25–7
governance, 56–7
purchasing issues, 108–23
see also funding models; specific
models/countries
hierarchies, coordination in, 52
home care, 31–2
248 Primary care in the driver’s seat?
home help services, 33–4
home helpers, 10
home nursing, 32–3
home nursing organizations, 32, 34
hospital care see primary-secondary care
interface
Hutten, J.B.F., 88
and Kerkstra, A., 10, 31–2, 34
Iceland, quality improvement policies, 213
ICPC see International Classification of
Primary Care
income, GP, 29–30
Independent Practice Association (IPA)
model, 140
indirect purchasing, 114–15
information and communication
technologies (ICT)
aspects of, 64, 73, 78
conditions for ICT-based primary care,
239–40
education and training in, 236–9
legal aspects and data safety, 237–9
need for, 231–6
role of, 228–31
informational continuity, 12–13
innovation in roles, 155
integrated capitation (payment) system, 186,
191
integrated care structures, Germany, 140
integration see coordination
internal market system, 134–5
International Classification of Primary Care
(ICPC), 229–30
international organizations
education role, 169–70
see also specific organizations
Internet, 232–3, 234–5, 236
Ireland
CME groups, 208, 216
payment system, 189
quality improvement policies, 216
Italy
payment system, 187, 189
purchasing (Imola project), 114–15
quality improvement policies, 216
job satisfaction, GPs, 40, 46
legal aspects of ICT, 237–9
liaison, specialist, 157
liberal model of education governance,
169
licensing see accreditation/reaccreditation
lifelong learning cycle, 178–80
local health agencies, 105, 106
managerial continuity, 12–13
market-based coordination, 51, 52, 58
medical cooperatives
in former Yugoslavia, 138
for out-of-hours services, UK, 139
see also GP partnerships/groups
medical records, 41, 44–5, 64
carnet de santé, France, 91
electronic, 229–30, 231
mental health care, 156–7
midwifery, 10
ministries of education, influence of, 166
ministries of health, influence of, 166–7
minor surgery, service transfer, 156
mixed payment systems, 186–8, 196
multiprofessional teams, 150–1
National Institute for Clinical Excellence
(NICE), 211
Netherlands, 8, 9–10
Almere experiment (vignette), 10–12
communication/workload problems,
87–8
coordination strategies, 94–6, 99
governance, 56, 59
nurse practitioners, 151, 152
payment system, 189
professional regulation, 53–4
quality improvement, 207–8, 209–10, 211,
214
sickness funds, 142
Steering Committee on Future Health
Scenarios, 60, 79–80
network coordination, 52–4
challenge of, 76–7
in purchasing, 113–14, 125, 126
see also coordination
networks
computer, 232–3
Finland, 113–14
France, 90–1, 92
Germany, 141
UK, 98
“New Public Management”, 133–4
NHS see United Kingdom (UK)
NICE see National Institute for Clinical
Excellence
non-gatekeeping systems, problems in, 88–90
nurse practitioners, 9
and physician assistants, 155
substitution, 154
nurse-led commissioning, 110
nursing profession, 9, 63
extended roles, 149, 150, 151–2, 153–4,
158–9
patient satisfaction with, 158–9
OECD, 5, 15, 25, 29, 29–30
organizational issues in purchasing, 116, 123
out-of-hours services, UK, 139
outpatient clinics, 156, 158
outreach clinics, UK, 97–8, 156, 158
patient access see access to care
patient empowerment, 86
Index
patient involvement in quality improvement,
220–1
patient satisfaction
payment system effects, 193–4
skill mix changes, 157–9
patient’s agent, GP as, 116–17
payment systems
effects
actual, 192–5
intended, 185–8
employment mode, 40–1, 41, 62
interaction with health system context,
188–92
policy implications, 195–6
promoting competition and contestability,
135–7, 144
skill mix changes, 151
peer control, 52–3
peer review groups, 207–9
Personal Medical Services (PMS) schemes, UK,
110–11, 136
personalized care, 86
pharmaceutical industry, influence of, 167–8
pharmacists, 9–10, 63
physician assistants, US, 155
physiotherapy, 10
Poland, quality improvement policies,
218
policy issues
payment systems, 195–6
public-private mix, 143–4
purchasing, 119
in skill mix, 150–1
political issues
accreditation/reaccreditation, 177–8
in health systems, 25–7
polyclinics, 112, 130–1
CEECs, 93–4
university polyclinics, Germany, 135
population ageing, 150
Portugal
payment system, 189
quality improvement policies, 216–17
practice certification, Germany, 211
practice environment, 63–5
practice equipment and diagnostic facilities,
39–40, 46
practice networks, Germany, 141
practice nurses, 9, 152
practice visiting, 209
Preferred Provider Organizations (PPO)
model, 140
prescribing, role of ICT, 228, 230
preventative medicine, 4–5
primary care
challenges, 4–5
comparison between European countries,
22–49
features and disciplines, 5–15
paradox, 16–17
potential of, 15–17
249
process, 6–7
working definition, 14–15
Primary Care Groups (PCGs)/Trusts (PCTs),
UK, 239
coordination, 97, 98–9
public-private mix, 141
purchasing, 109, 110, 111
Primary Health Care (PHC)
networks, 138–40
settings, CEECs, 89–90, 93–4, 129
primary-secondary care interface
CEECs, 90
France, 89, 92
Netherlands, 95–6
UK, 87
see also coordination; gatekeeping; Primary
Care Groups (PCGs)/Trusts (PCTs), UK
private health insurance, 142–3, 191
private pension schemes, GPs, 143
private primary care provision, 137, 143
private training bodies, 167–8
privatization, 55, 93
impact of, 142–3
strategies, 137
see also public-private mix
profession dominated model of education
governance, 169
professional bodies
France, 91, 92
influence on education, 166
self-regulation by, 53–4, 55, 62–3, 177
skill mix changes, 151–2
professions
impact of skill mix changes, 151–2, 159–60
preconditions for purchasing, 123–4
see also disciplines (other than GPs)
provider behaviour, effects of payment
systems, 192–3
public-private mix
competition and contestability, 135–7, 144
conceptual framework, 129–33
examples, 138–44
policy lessons, 143–4
private primary care provision, 137, 143
reforms, 133–5, 140–3
situation before 1990, 130–3
see also privatization
purchaser/provider split
Catalonia, Spain, 111
Sweden, 115
purchasing
alternative developments, 125–6
benefits
practical, 116–17
theoretical, 105–6
contextual preconditions for, 123–5
continuum, 106
development of, 105
in different health systems, 108–15
comparing theory and practice, 115–21
evaluation, 121–3
250 Primary care in the driver’s seat?
factors associated with failure, 118–21
implementation problems, 117–18
models, 107
range of contract tools in, 106–7
quality, definition of, 204, 222
quality of care, purchasing, 116
quality circles, 207–9
quality improvement, 204–5
diffusion throughout Europe, 205–6
emerging trends, 219–21
future developments, 221–3
methods and their effectiveness, 206–11
national policies, 211–19
role of ICT, 228–31
quality improvement cycle, 205
quality management techniques, 211
quasi-market system, 134–5
Rathwell, T. et al., 74–5
RCGP see Royal College of General
Practitioners, UK
reaccreditation see
accreditation/reaccreditation
records see medical records
referral see gatekeeping
‘referring physician’, France, 90–1, 92
reforms, 51–4
context, 54–8
Juppé reforms, France, 91
public-private mix, 133–5, 140–3
requirements for coordination, 61–5
towards new care arrangements, 58–61
regulation dominated model of education
governance, 169
relational continuity, 12–13
relocation of specialists to general practice,
156–7
resources for primary care, 28–31, 64
Rhodes, R.A.W., 143–4
Romania, family medicine (vignette), 26–7
Royal College of General Practitioners
(RCGP), UK, 8
Russian Federation, purchasing in, 112,
120–1
salary system, 192
effects, 186, 193, 194, 195
funding, 191
policy conclusions, 195–6
Saltman, R. and Von Otter, C., 25, 135, 138
Saltman, R.B., 77, 77–8, 79
and Busse, R., 55, 57, 58
and Dubois, H.F.W., 57
et al., 16
and Figueras, J., 3, 15, 57
science dominated model of education
governance, 169
secondary care see primary-secondary care
interface
self-employed GPs, 40–1, 136
self-regulation by professional bodies, 53–4,
55, 62–3, 177
Semashko system see Soviet model
service transfer, from hospitals to GPs,
155–6
Sheaff, R., 15, 129, 142
SHI see social health insurance model
(Bismarck system/SHI)
Shi, L.
et al., 15, 87
Starfield, B. and, 3
sickness funds, 91, 92, 105, 106, 142, 143
skill mix changes
factors governing, 149–52
impact on care, 153–7
impact on professionals, 151–2, 159–60
mechanisms of, 152–3
patient acceptability, 157–9
Slovenia
primary care (vignette), 37–9
quality improvement policies, 218
social health insurance model (Bismarck
system/SHI), 25, 42, 44–5, 46, 75,
79–80
governance, 55–6
payment system, 191
pre-1990, 129, 130, 131–2, 132–3
purchasing, 105, 106
reforms, 135, 136
sickness funds, 91, 92, 105, 106, 142,
143
Soviet model (Semashko system), 25, 74, 75
1990 reform, 133, 135
pre-1990, 129, 130–1, 132
transitional countries, 43, 45, 46, 56
Spain
1980s reforms, 134
Entitat de Base Asociativa (EBAs), Catalonia,
139
payment system, 190
private health insurance, 142–3
public-private mix, 132
purchasing in Catalonia, 111, 119, 120
specialist GPs, 100, 154
training, 172, 173
specialist services, 155–7
Starfield, B., 6, 7, 15, 60, 68, 69, 87, 170, 192
Forrest, C.B. and, 28
and Shi, L., 3
“state agent” role, 75, 77, 79
stroke units, Netherlands, 96
structural reform see reforms
substitution, nurse practitioners, 154
Sweden, 56–7
failed purchasing attempt, 115, 119–20, 121
networks of cooperation, 125
payment system, 190
quality improvement, 209, 214
Switzerland, quality improvement, 217
task profiles see skill mix changes
Index
tax funded model (Beveridge system), 25, 42,
44, 46, 75
governance, 55, 56
payment systems, 191
pre-1990, 130, 130–1, 132–3
purchasing, 105, 106
teamwork
GPs, 13–14, 36–7, 44–5, 64
impact on professionals, 159–60
multiprofessional, 150–1
telemedicine, 233–4
Temmink, D., 95
et al., 9, 14, 61
Total Purchasing Pilots (TPPs), 108–9
training see education
transitional countries see central and eastern
European countries (CEECs); Soviet
model (Semashko system); specific
countries
transmural care, Netherlands, 95–6
Turkey, quality improvement, 219
undergraduate education, 171–2
United Kingdom (UK)
challenges, 99–100
coordination strategies, 97–9
extended nursing roles, 152
governance, 56, 58–60
health informatics training, 236
medical cooperatives for out-of-hours
services, 139
mental health care, 156–7
networks of cooperation, 125
NHS Direct, 100
NHS Walk-in Centres, 100
251
payment system, 151, 187, 190
Personal Medical Services (PMS) schemes,
110–11, 136
purchasing in, 108–11, 119, 120, 122, 123
quality improvement, 209, 210–11, 214–15
recertification, 176
Royal College of General Practitioners
(RCGP), 8
service transfer, 156
see also Primary Care Groups (PCGs)/Trusts
(PCTs), UK
United States (US)
mental health care, 156–7
payment system, 151
physician assistants, 155
universities
influence on education, 166
polyclinics, Germany, 135
Van der Linden, B.A., 95–6
Van der Zee, J., 7
et al., 5, 55
Van Weel, C., 9, 14
and Rosser, W.W., 65
Rosser, W.W. and, 41
walk-in clinics, 100, 138
workload, 88
World Health Organization (WHO), 3, 15, 28
Alma Ata Declaration, 5, 6, 74
educational role, 169–70
Europe, 74, 169–70, 205–6
World Organization of National Colleges and
Academies (WONCA), 170, 179, 206,
229
Related books from Open University Press
Purchase from www.openup.co.uk or order through your local bookseller
SOCIAL HEALTH INSURANCE SYSTEMS IN WESTERN
EUROPE
Richard B. Saltman, Reinhard Busse and Josep Figueras (eds)
•
•
•
What are the characteristics that define a Social Health Insurance system?
How is success measured in SHI systems?
How are SHI systems developing in response to external pressures?
Using the seven Social Health Insurance countries in western Europe – Austria, Belgium,
France, Germany, Luxembourg, the Netherlands and Switzerland – as well as Israel, this
important book reviews core structural and organizational dimensions, as well as recent
reforms and innovations.
Covering a wide range of policy issues, the book:
•
•
•
•
Explores the pressures these health systems confront to be more efficient, more
effective, and more responsive
Reviews their success in addressing these pressures
Examines the implications of change on the structure of SHI’s as they are currently
defined
Draws out policy lessons about past experience and likely future developments in SHI
systems in a manner useful to policymakers in Europe and elsewhere
Social Health Insurance Systems in Western Europe will be of interest to students of health
policy and management as well as health managers and policy-makers.
Contributors
Helmut Brand, Jan Bultman, Reinhard Busse, Laurent Chambaud, David Chinitz, Diana
M.J. Delnoij, André P. den Exter, Aad A. de Roo, Anna Dixon, Isabelle Durand-Zaleski,
Hans F.W. Dubois, Josep Figueras, Bernhard Gibis, Stefan Greβ, Bernhard J. Güntert, Jean
Hermesse, Maria M. Hofmarcher, Martin McKee, Pedro W. Koch-Wulkan, Claude Le Pen,
Kieke G.H. Okma, Martin Pfaff, Richard B. Saltman, Wendy G.M. van der Kraan, Jürgen
Wasem, Manfred Wildner, Matthias Wismar.
Contents
List of contributors – Introduction – Foreword – Acknowledgements – Part One – Social
health insurance in perspective: the challenge of sustaining stability – The historical
and social base of social health insurance systems – Organization and financing of social
health insurance systems: current status and recent policy developments – Patterns and
performance in social health insurance systems – Assessing social health insurance systems: present and future policy issues – Part Two – The challenge to solidarity –
Governance and (self-)regulation in social health insurance systems – Solidarity and competition in social health insurance countries – Key organizational issues – Shifting Criteria
for benefit decisions in social health insurance systems – Contracting and paying providers
in social health insurance systems – The role of private health insurance in social health
insurance countries – The changing role of the individual in social health insurance systems
– Beyond acute care – Prevention and public health in social health insurance systems –
Long-term care in social health insurance systems – Index.
328pp
0 335 21363 4 (Paperback)
0 335 21364 2 (Hardback)
HEALTH POLICY AND EUROPEAN UNION ENLARGEMENT
Martin McKee, Laura MacLehose and Ellen Nolte (eds)
European national policy makers broadly agree on the core objectives that their health
care system should pursue. The list is straightforward: universal access for all citizens,
effective care for better health outcomes, efficient use of resources, and high quality
services responsive to patients’ concerns. It is a formula that resonates across the political spectrum and which, in various, sometimes inventive configurations, has played a
role in most recent European national election campaigns.
While there may be consensus on the broader issues, expectations differ between EU
countries, and, with the enlargement of 2004, matters become more complex. This
book seeks to assess the impact of the enlargement process and to analyse the challenges that lie ahead in the field of health and health policy. Written by leading health
policy analysts, the book investigates a host of areas including:
•
•
•
•
•
health care investment
international recruitment of nurses and doctors
health and safety
communicable disease control
European pharmaceutical policy
Health Policy and European Union Enlargement will be of interest to students of health
policy, economics, public policy and management, as well as health managers and
policy makers.
Contents
Health and enlargement – The process of enlargement – Health status and trends in candidate countries – Health and health care in the candidate countries to the European Union:
Common challenges, different circumstances, diverse policies – Investing in health for
accession – Integration of East Germany into the EU: Investment and health outcomes –
The challenges of the free movement of health professionals – Free movement of health
professionals: The Polish experience – The market for physicians – Not from our own backyard? The United Kingdom, Europe and international recruitment of nurses – Free movement of patients – Closing the gap: Health and safety – Communicable disease control:
Detecting and managing communicable disease outbreaks across borders – Free Trade
versus the protection of health: The examples of alcohol and tobacco – Opportunities for
inter-sectoral health improvement in new Member States – the case for health impact
assessment – European pharmaceutical policy and implications for current Member States
and candidate countries – Lessons from Spain: Accession, pharmaceuticals and intellectual
property rights – Looking beyond the new borders: Stability Pact countries of south-east
Europe and accession and health – Index
312pp
0 335 21353 7 (paperback)
0 335 21354 5 (hardback)
HUMAN RESOURCES FOR HEALTH IN EUROPE
Carl-Ardy Dubois, Martin McKee, and Ellen Nolte
Health service human resources are key determinants of health service performance. The
human resource is the largest and most expensive input into healthcare, yet it can be the
most challenging to develop. This book examines some of the major challenges facing
health care professions in Europe and the potential responses to these challenges.
The book analyses how the current regulatory processes and practices related to key
aspects of the management of the health professions may facilitate or inhibit the development of effective responses to future challenges facing health care systems in Europe.
The authors document how health care systems in Europe are confronting existing
challenges in relation to the health workforce and identify the strategies that are likely to
be most effective in optimizing the management of health professionals in the future.
Human Resources for Health in Europe is key reading for health policy-makers and
postgraduates taking courses in health services management, health policy and health
economics. It is also of interest to human resource professionals.
Contributors
Carl Afford, Rita Baeten, James Buchan, Anna Dixon, Carl-Ardy Dubois, Sigrún
Gunnarsdóttir, Yves Jorens, Elizabeth Kachur, Karl Krajic, Suszy Lessof, Ann Mahon, Alan
Maynard, Martin McKee, Ellen Nolte, Anne Marie Rafferty, Charles Shaw, Bonnie
Sibbald, Ruth Young.
Contents
Foreword – Human resources for health in Europe – Analysing trends, opportunities and
challenges – Migration of health workers in Europe: policy problem or policy solution? –
Changing professional boundaries – Structures and trends in health profession education
in Europe – Managing the performance of health professionals – Health care managers as
a critical component of the health care workforce – Incentives in health care: the shift in
emphasis from the implicit to the explicit – Enhancing working conditions – Reshaping the
regulation of the workforce in European health care systems – The challenges of transition
in CEE and the NIS of the former USSR – The impact of EU law and policy – Moving forward:
building a strategic framework for the development of the health care workforce – Index.
288pp
0 335 21855 5 (Paperback)
0 335 21856 3 (Hardback)
PURCHASING TO IMPROVE HEALTH
SYSTEMS PERFORMANCE
Edited by Josep Figueras, Ray Robinson and Elke Jakubowski
Purchasing is championed as key to improving health systems performance. However,
despite the central role the purchasing function plays in many health system reforms,
there is very little evidence about its development or its real impact on societal objectives. This book addresses this gap and provides:
•
•
•
•
A comprehensive account of the theory and practice of purchasing for health services
across Europe
An up-to-date analysis of the evidence on different approaches to purchasing
Support for policy-makers and practitioners as they formulate purchasing strategies
so that they can increase effectiveness and improve performance in their own
national context
An assessment of the intersecting roles of citizens, the government and the providers
Written by leading health policy analysts, this book is essential reading for health policy
makers, planners and managers as well as researchers and students in the field of health
studies.
Contributors
Toni Ashton, Philip Berman, Michael Borowitz, Helmut Brand, Reinhard Busse, Andrea
Donatini, Martin Dlouhy, Antonio Duran, Tamás Evetovits, André P. van den Exter, Josep
Figueras, Nick Freemantle, Julian Forder, Péter Gaál, Chris Ham, Brian Hardy, Petr Hava,
David Hunter, Danguole Jankauskiene, Maris Jesse, Ninel Kadyrova, Joe Kutzin, John
Langenbrunner, Donald W. Light, Hans Maarse, Nicholas Mays, Martin McKee, Eva
Orosz, John Øvretveit, Dominique Polton, Alexander S. Preker, Thomas A. Rathwell,
Sabine Richard, Ray Robinson, Andrei Rys, Constantino Sakellarides, Sergey Shishkin,
Peter C. Smith, Markus Schneider, Francesco Taroni, Marcial Velasco-Garrido, Miriam
Wiley.
Contents
List of tables – List of boxes – List of figures – List of contributors – Series Editors’ introduction – Foreword – Acknowledgements – Part One – Introduction – Organization of
purchasing in Europe – Purchasing to improve health systems – Part Two – Theories of
purchasing – Role of markets and competition – Purchasers as the public’s agent – Purchasing to promote population health – Steering the purchaser: Stewardship and government –
Purchasers, providers and contracts – Purchasing for quality of care – Purchasing and
paying providers – Responding to purchasing: Provider perspectives – Index.
320pp
0 335 21367 7 (Paperback)
0 335 21368 5 (Hardback)
Primary care in the driver’s seat?
Organizational reform in European primary care
• What is the best way to structure primary care services?
• How can co-ordination between primary care and other parts of health
care systems be improved?
• How should new technologies be integrated into primary care?
There is considerable agreement among national policy makers across
Europe that, in principle, primary care should be the linchpin of a welldesigned health care system. This agreement, however, does not carry over
into the organizational mechanisms best suited to pursuing or achieving this
common objective. Across western, central and eastern Europe, primary
care is delivered through a wide range of institutional, financial, professional
and clinical configurations. This book is a study of the reforms of primary
care in Europe as well as their impacts on the broader co-ordination
mechanisms within European health care systems. It also provides
suggestions for effective strategies for future improvement in health care
system reform.
Primary Care in the Driver’s Seat is key reading for students studying health
policy, health economics, public policy and management, as well as health
managers and policy makers.
The editors
Richard B. Saltman is Professor of Health Policy and Management at
the Rollins School of Public Health, Emory University in Atlanta, USA
and Research Director at the European Observatory on Health Systems
and Policies.
Ana Rico is Assistant Professor of Health Politics at the Department of Health
Management and Health Economics at the University of Oslo, Norway.
Wienke Boerma is Senior Researcher at the Netherlands Institute of Health
Services Research (NIVEL) in Utrecht, the Netherlands.
The contributors
Richard Baker, Sven-Eric Bergman, Wienke Boerma, Mats Brommels,
Michael Calnan, Diana Delnoij, Anna Dixon, Carl-Ardy Dubois, Joan Gené
Badia, Bernhard Gibis, Stefan Greß, Peter Groenewegen, Jan Heyrman, Jack
Hutten, Michael Kidd, Mårten Kvist, Miranda Laurant, Margus Lember,
Martin Marshall, Alison McCallum, Toomas Palu, Ana Rico, Ray Robinson,
Valentin Rusovich, Richard B. Saltman, Anthony Scott, Rod Sheaff, Igor
Svab, Bonnie Sibbald, Hrvoje Tiljak, Michel Wensing.
ISBN 0-335-21366-9
www.openup.co.uk
9 780335 213665