family medicineas a cornerstoneforthe ... - wonca europe
TRANSCRIPT
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Family medicine as a cornerstone for the primaryhealth care reform: the Latvian experience.
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• Countries that have based their health care system on family medicine reveal better health indicators and higher efficiency of the entire health care system
• Strong primary health care and family medicine allows to prevent fragmentation of care, ensures continuity of health care process and better coordinated approach to treatment process
• Initiative to start the training and re-training in family medicine from medical students and practising medical doctors.
Why family medicine?
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Territory - 64 559 square kilometres (about twice the size of Belgium).
Inhabitants 1.96 million in 2016Capitals city - Riga with 650 000 inhabitants
Forests covering 47% of the land area and forming Latvia’s most important natural resource.
LATVIA
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• Mainly hospital based
• Primary health care : polyclinics – adult and children:o in cities and towns provided by district
internist and district paediatricianso in rural areas primary health care very
often provided by feldsher ( physician’s assistant)
THE HEALTH CARE SYSTEM IN LATVIA BEFORE 1991
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• 1990 - 1991 - the first specialists willing to be retrained as family doctors, the re-training and the development of residency was initiated by medical doctors and students
• 1991 - 1993 – the first programme in family medicine residency at the Latvian Academy of Medicine
THE FIRST DECADE AFTER REGAINING INDEPENDENCE
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• 1992 - Foundation of the Association of Family Physicians , now the very important stakeholder in health care in Latvia
• 1995 - 1996 - the Latvian Association of Family Physicians sets up a retraining courses in family medicine (2 months long)
THE FIRST DECADE AFTER REGAINING INDEPENDENCE
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• 1994 - 1999 - Riga City develops and implements primary health care strategy in collaboration with the National Health Service (NHS) in the UK
• 1999 - the job description of the family (general practice) physician’s specialty is revised and aligned with other associations ( 1997 – the first edition)
• 1999 - PHARE project on family medicine postgraduate training and continuous strengthening of vocational training
THE FIRST DECADE
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• 1999 – 2001 - World Bank project focused on reorganization of primary health care in Latvia
• 2000 - 2001 - World Bank Project to support retraining of district internists and pediatricians, enabling them to work in family medicine ( From 2004 only family physicians could have the contract with NHS)
• 2000 - implementation of capitation with fund holding as the provider payment method for family physicians at PHC level all across Latvia, except Riga
YEARS 2000 - 2004
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• Tremendous reduction in funding for health sector , including the primary health care in 2009, due to economic crisis, with slow increase of funding for PHC since 2015.
• Experiment to re-introduce the district pediatrician at the PHC level in 2010 which was abolished in 2012 because of low patients’ activity to register with pediatricians. Although there is a new proposal to re-introduce PHC pediatricians in 2018
• Introduction of quality criteria and pay for performance (P4P) for family physicians since2009
2004 - 2018
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NUMBER OF FAMILY DOCTORS 1991 - 2018
0
200
400
600
800
1000
1200
1400
1600
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NUMBER OF FAMILY DOCTORS ON 10000 INHABITANTS
0
1
2
3
4
5
6
7
8
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
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ACADEMIC EDUCATION IN FAMILY MEDICINE
• The programme in family medicine at thefaculty of medicine, University of Latvia estbalished in 2000 (faculty was re-established in 1998 after being closeddown in 1948)
• The Department of family medicineestablished at the P.Stradin’s RigaUniversity in 2010/2011
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• The Certification after the residency training
• The periodical re- certification every five years:o Continuing education trainings organized
by the Latvian Medical association, the Latvian association of family doctors , medical schools other professional associations
o the international conferences and seminars
o small group peer review and quality circles
CONTINUING EDUCATION IN FAMILY MEDICINE
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• Number of family physicians in Latvia about 1500
• Number of family physicians having contract with NHS : 1322
• Number of family physicians working in Riga : 446
• Number of family physicians working in regions: 886
CURRENT SITUATION IN LATVIA
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• 1800 enrolled person assigned to the one family physician
• 14% of practices have more than 2000 but in average 1543 patients are assigned with on family physician
• Family physician may have several consultation rooms in different places if working in rural areas
STRUCTURE OF THE FAMILY PHYSICIAN’S PRACTICE
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• HC budget in 2017 – 820 490 million Euros• Through the general taxation but in 2019 it is
planned to introduce mandatory health insurance
• HCB is 9.6 % of the Latvian government budget
• 9 % only from HC budget is spent of PHC , including payment for family physicians’work
• Family physicians have 5.9 million visits a year , in average 3 visits per one registered patient.
• 70 % of all patients visits during the year
SPENDING ON HEALTH CARE AND PRIMARY HEALTH CARE
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VARIETY OF MEDICAL PROCEDURES PERFORMED BY FAMILY DOCTORS
0102030405060708090
100 92 8883
74 7365 62 58
5348 44
34
5 71 1 1 2 6 8
27
18 19 1929
70 74
Already doingAlready doing but could be done moreI am not doing it at the moment but would do if I would have resources
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WHAT ARE THE MAIN OBSTACLES IN DAILY WORK OF FAMILY PHYSICIANS?
02468
101214
14 14 1312
108
74 4
3 32 2
1 1 2
%
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SATISFACTION WITH DIFFERENT ASPECTS OF PROFESSIONAL WORK OF FAMILY DOCTORS
0
10
20
30
40
50
60
70
80
90 90 89
59
40
17
57
38
57
83
37
97
25 29
49
33
47
32
14 14
2 4
17
31 35
915 12
4
48
Satisfied Not satisfied, not dissatisfied Not satisfied
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FINBALT SURVEY IN 2016:
• 60 % of respondents were satisfied with their family physician.
PATIENTS SATISFACTION
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• Lack of stabile long -term strategy for the PHC
• Insufficient co-operations among family physicians and specialists
• Bureaucratic burden of medical records and paperwork in the daily work of family physicians
CHALLENGES
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• Dependence of continuing education in family medicine on sponsors
• Insufficient horizontal cooperation , e.g., at the municipality level with other services .
• Introduction of e-health, at the moment for prescribing medicines and sick-leaves
CHALLENGES
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• To identify strengths and weaknesses of the primary health care and family medicine, and to establish primary health care strategy to address the existing deficiencies ( at least for 10 years period)
FUTURE ACTIONS
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• To promote independent continuing education for family doctors, which would be independent of pharmaceutical industry and drug wholesalers
FUTURE ACTIONS
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• To build such health care strategies that promote co-operation between general practitioners as primary health care providers and specialists in order to work as a joint team in providing quality healthcare to the Latvian population
FUTURE ACTIONS
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• To convince the MOH and the Government of Latvia about the necessity to increase the spending on PHC
• To keep the payment for capita as the financing model for PHC with additional P4P scheme
FUTURE ACTIONS
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• To expand the primary health care team with the involvement of a physiotherapist and midwife ( in rural areas).
• To motivate using P4P family physicians to cover broader spectrum of services provided at the PHC level.
FUTURE ACTIONS
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• Introduction of family medicine started in Latvia 28 years ago as an initiative from medical students and practising doctors
• With support form international partners the Latvian Government moved ahead to reform the health care system strengthening PHC in the 90’s
• Only 9 % of the health care budget is spent on PHC
IN CONCLUSION
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• Today 1322 family physicians are covering the almost 70 % of patients’ needs for health care in Latvia , serving 5.9 million visits a year and in average seeing every patient 3 times a year
• In average on family physician has 1543 patientsin the enrolment list
• Family physicians provide the variety of services, including monitoring of pregnancy, care of new-borns and babies, child care, small surgical operations and other.
• 60 % of patients are satisfied by the advice and care provided by family physicians
IN CONCLUSION
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• Family medicine has become a cornerstone for PHC in Latvia being a very effective way providing health care for patients
• The Association of Family Medicine in Latvia, also the member of the Latvian Medical Association has played a great role in designing the health sector reform, developing postgraduate and continuing education in family medicine
• To strengthen the latest developments a long-term strategy should be not only developed but also executed without frequent deviations due to political changes
IN CONCLUSION
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• There always is a place for the development and reform in health sector but too frequent changes do not lead us to better results.
IN CONCLUSION
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• http://www.csb.gov.lv/dati/statistikas-datubazes-28270.html
• http://eu.baltic.net/Project_Database.5308.html?contentid=28&contentaction=single
• http://www.lgaa.lv
REFERENCES