modelli di funzionamento delle cure territoriali in europa (giorgio visentin)

Visentin G. 28/10/2009

Modelli di funzionamento

delle cure territoriali in

Europa


FAMILY PHYSICIANS IN EUROPE

Prof. Igor ŠvabVice-president ESGP/FM

University of Ljubljana, Slovenia

General Practice General Practice -- Family Medicine Family Medicine in The in The NetherlandsNetherlands

-- daily work in a GP officedaily work in a GP office-- key figures and organizational aspectskey figures and organizational aspects-- values of (Dutch) primary carevalues of (Dutch) primary care-- current issuescurrent issues

BRITISH GENERAL PRACTICEBRITISH GENERAL PRACTICE

A CHANGING SCENEA CHANGING SCENE

Dr Philip R Evans FRCGPDr Philip R Evans FRCGP

Cascais, Portugal 2008

COMISIÓN NACIONAL DE MEDICINA FAMILIAR Y COMUNITARIA

Ministerio de Sanidad y Políticas SocialesMinisterio de Educación

Lisboa 23 de mayo de 2009

Finnish Health Care System

Mikko ValkonenMD

Chair of the General Practicioners in Finland GPF

Dpt. of General Practice/Family MedicineUniversity of Duisburg-Essen

Organization of General Practicein Germany

Conference of the Portuguese Association of General PractitionersLisbon, 23. May 2009

Thomas QuellmannDep. Of General Practice/Family Medicine

University of Duisburg-Essen, Germany

Switzerland

26 cantons

UEMO – WONCA Meeting

Family Doctors Future

Isabel CaixeiroUEMO President

European Union of GeneralPractitioners/Family Physicians

Created in 2005Created in 2005


MAIN MODELS IN EUROPE

• Regulated model• Liberal model• Salaried system• Shemashko model• Yugoslav model


REGULATED MODEL

• Based on a complex contract between the payer and the GP

• In countries, where general practice is well developed

• State as the main payer• Regulated profession

(accreditation, vocational training)

• Mostly group practices


LIBERAL MODEL

• Western Europe, general practice less developed

• State important payer• Not very well

regulated profession• Solo practices

common


SALARIED SYSTEM

• East and West• GPs paid by the health

centre• Very regulated

profession• Health centres as the

predominant organisational form


THE SHEMASHKO MODEL

• In former USSR and its satellites

• Based on policlinics

• Salaried GPs with low esteem

• Abandoned (low satisfaction, low quality, low motivation for better work)


YUGOSLAV MODEL

• In former Yugoslavia• Based on primary

health centres• Salaried GPs,

recognised as speciality

• Survived with modifications in some countries


United Kingdom

• A history and tradition of independent solo practice

• Introduction of NHS• Later experiments and

changes (fundholding etc.)

• Situation now: health care trusts


Holland

• Tradition of solo practice

• Move towards group practices


Slovenia

• Legacy of socialist care with health centres

• Vocational training since 1961

• University department since 1994

• Still growing importance


Italy(a personal impression)

• A long standing tradition of solo practice

• Rapid growth of academic general practice

• Excellent prospects for the future


THE KEY FACTORS OF SUCCESS

• Dialogue with key players

• Maintaining quality standards

• Coordination of efforts• Maintaining core

values, but protecting individuality


Political background - Demographics

Age Distribution : 2008 vs. 2050


German Health Care SystemOtto von Bismarck (1815-

98)• Inauguration of the Social

Insurance Legislation in 1883

• Introduction of mandatory Health Insurance

• Accident Insurance • Employers Liability


Health Insurance System in Germany

Social Health Insurance System / Statutory Health

Insurance (SHI)

• 70 million out of a population of 82 million people are covered by SHI

• The principle is that rich pay for the poor, the young for the old, the healthy for the sick (solidarity)

• SHI is a family insurance, children and unemployed spouses are co-insured free of charge


German Health Care System

Health Care SystemSources of Health Insurance Coverage

Number of Residents: 81,996 million

• Statutory Health Insurance 88.5 % of Pop.• Private Health Insurance 8.9 %• Other Coverage 2.4 %• Uninsured 0.2 %


German Health Care System

Population by Source of Coverage (mill.):

Statutory Health Insurance 72,567 • Regional Sicknes Funds (AOK) 30,365• Substitute Funds (Ersatzkasse) 25,215• Company-Based Funds (BKK) 9,116• Guild- Funds (IKK) 4,877• Other (Miner-Farmer-Sailor) 2,724

Private Health Insurance 7,30


Health Insurance System in Germany

• Workers who earn less than 4.050 € a month are insured on a mandatory basis, as are unemployees, pensioners, students and poor people

• Employees pay 7,5 % of their salary for the coverage

• Employers pay the rest and have to continue payment of wages for 6 weeks in case of sickness.


Statutory Health Insurance ( SHI )

Regulation of Demand through co-payment

• 10 € per three month in outpatient care• Maximum 10 € per perscription of

pharmaceuticals• 10 € per day in inpatient care (first 2 weeks )• Maximum: 2% of income (1% for chronically ill

persons)


Private Health Insurance ( PHI )

• PHI is not part of the Social Security System• Persons with an income above SHI border or those

who are self-employed can stay in the SHI on a voluntary basis or purchase PHI

• Members of a PHI pay risk-based premiums• Many persons in SHI choose a PHI for inpatient-

care (hospital)


Physicians in hospital and practice

Physicians in Hospitals and Practices

• Number of working Physicians 319.700• General Practitioners 58.500• Specialists in private practices 61.300• Physicians in Hospitals 153.800


Physicians in hospital and practiceAmbulatory Care – outpatient care

• Majority of physicians practice in single practices• Trend towards practices with several colleagues• Multi –speciality clinic-models • Free choice of doctor (including specialists)• „Freeway“ by the insurance chip card• Benefit for patients using primary care doctors as

„pilots“


Payment System

• SHI – mixed tariff

Lump sums (budget) and fees for special

examinations

• PHI – fixed prices for every service

p.e. : ECG, Ultrasonic, Spirometry


Health Information System • Electronic Patient Card

• Data Centre

• Interconnectedness

• Data security

• Vitreous Patient


Health Information System Data storage:• Prescreptions • Allergies• Incomptibilities• Diagnoses• Former diseases• Hospital reports• Documents, Patient file

European Health Insurance Card


Satisfaction of patients with Health Care System

70

54

38

35

20

11

4

10

2

22

38

47

39

45

45

47

43

26

4

3

11

9

30

22

22

28

42

2

4

4

10

9

20

20

17

22

2

1

1

6

5

8

8

2

8

Austria

Denmark

France

United Kingdom

Germany

Spain

Portugal

Czech Republic

Estonia

very satisfied more satisfied partly satisfied more dissatisfied very dissatisfied


Satisfaction of patients with Primary Care

90 % of patients (4.315 persons 18 -73 years)

are very content with medical accomplishments

and services of their GP(KBV, 2006)

Directed steering by the GP brings better results

for the treatment and the reduction in costs(KV Sachsen Anhalt 2007 )


Satisfaction of professionals in Health Care System

• Satisfaction of physicians in hospitals

• Satisfaction of specialists in outpatient care

• Satisfaction of General Practitioners

• Satisfaction with Primary Care


Politics and Health Care - Summary

„Health care is on a collision course with patients

needs and economic reality.“ Dr. Luis Pisco, WONCA 2008, Istanbul

The German Health care System is at this high stage not longer financeable

Quellmann, Conference of the Port.Ass.Gen.Pract. 2009, Lisbon


Politics and Health Care - Summary

Priority setting necessary?A new German Discussion

• Global economy crisis reduce state revenue• Increase of unemployment shock the

German Health Care System, the pension scheme and the Care Insurance

• 6% of Gross domestic product is not enough


Summary

• General organization of primary care is regulated by Assoc. of statutory health insurance physicians

• Payment system in PHI means: lump sums PHI means: fixed prices

• Further education is the task of General medical council – 5 years for GP s

• Electronic patient card – supporters- opponents• Satisfaction of patients with the GP is high• Satisfaction of many GP‘s are low


GP: Present and Future

Visiting Nurses:

Valued assistant

against a rainy day

A „strong comeback“


accesibilidad universal y cobertura

pública

La financiación pública:

presupuestos generales del Estado

(PIB 7.2%)

Descentralización política y de gestión en las Comunidades

Autónomas

Organización territorial en Áreas de Salud y ZBS Salud definidas por las

CCAA

Gestión pública y provisión,

fundamentalmente pública

La extensión a toda la población (44 m.

habitantes)

Acceso a la asistencia a través de

la Atención Primaria

Cartera de servicios amplia y Definida en RD 1030/2006


Esperanza de vida al nacer: 80.23 años. Mujer 83.48

Esperanza de vida en buena salud a los 65 años: 7 años

Esperanza de vida libre de incapacidad a 65 años : 12 años

Índice de dependencia general: juvenil 25.08, ancianos 24.26

Tasa de mortalidad infantil: 3.78/1000 nacidos vivos

Tasa de natalidad: 10.75/1000 habitantes

Tasa bruta de mortalidad: 8.92/1000 habitantes

Tasa de mortalidad ajustada por edad: 568.46/100.000

Crecimiento vegetativo: 0.18/100

Tasa de mortalidad por cardiopatía isquémica: 56.31/100.000 Tasa de mortalidad por cáncer: 159.73/100.000 Tasa de mortalidad por accidentes: 23.27/100.000


Encuesta de salud

El 96,6% dispone de un buen apoyo

social

el 93,4% buena función familiar

El 21,3% presenta riesgo de mala salud mental

El 70,0% percibe su estado de salud como bueno o muy bueno

El 26,4% de la población de 16 y más años fuma a

diario

48,4% consume habitualmente bebidas

alcohólicas (consumo de riesgo 7% en hombres y

del 3% en mujeres

El 60,6% realiza actividad física en

su tiempo libre

4/10 adultos sobrepeso y 1,5 obesidad. Niños 2/10 sobrepeso y 1/10 obesidad.


El 84.47% de las personas están satisfechas con la atención recibida por su médico de familia

El 76.97% de las personas están satisfechas con la atención recibida en el servicio de urgencias

El 81.61% de las personas están satisfechas con la atención recibida por el especialista del segundo nivel

El 83.34 % de las personas están satisfechas con la atención recibida durante el ingreso hospitalario


158 áreas de salud 2679 zonas básicas 2913 centros de salud. 10178 consultorios locales

27395 médicos de familia: 37%. 6087 pediatras. 27300 enfermeras Ratio tarjetas asignadas 1426

856 centros de salud y 214 hospitales acreditados para docencia postgrado.

2143 plazas acreditadas.124 centros de salud universitarios

97 Unidades Docentes de Medicina de Familia (MFyC)

Recursos Recursos estructuralesestructurales


CARACTERÍSTICAS IMPORTANTES DE LA ORGANIZACIÓN

MULTIDISCIPLINARIDAD

Médicos de familia

Pediatras

Enfermeras/os

Matronas

Trabajadores sociales

Personal administrativo

Otros

EQUIPOS DE APOYO A LA ATENCIÓN PRIMARIA

Centros de Salud Mental

Unidades de Fisioterapia

Unidades de Salud Bucodental


ACTIVIDAD EN ATENCIÓN PRIMARIA 1994 2007

Consultas Médico de Familia y Pediatra (millones)

212.8 309.6

Consultas por habitante y año 5.4 7.4

HOSPITALIZACIÓN

Altas (millones) 4.18 4.87

Altas por mil habitantes 106.8 118.6

Estancia media (días) 10.5 8.7

CONSULTAS

Consultas (millones) 39.4 68.2

Consultas por habitante/año 1.1 1.6

URGENCIAS

Urgencias (millones) 15.2 23.3

Urgencias por habitante/año 0.39 0.55

Fuente Ministerio de Sanidad y Consumo. Disponible en http://www.msc.es/estadEstudios/estadisticas/docs/FOLLETO-BAJA.PDF

http://www.msc.es/estadEstudios/estadisticas/docs/FOLLETO-BAJA.PDF


Farmer y cols. (1991) fueron los primeros en demostrar con datos obtenidos de todos los condados de los EEUU, que los condados con menos tasas de mortalidad ajustada por edad eran aquellos con mayor densidad de médicos de familia. Asimismo, otros estudios demuestran el impacto que los médicos de familia y la Atención Primaria tienen sobre la accesibilidad, la longitudinalidad, la relación médico-paciente, así como sobre la globalidad y la relación que estas características tienen sobre los niveles de salud (Starfield 2001, Macinko J 2003, Saltman RB 2006, Boerma 2006, Grishaw 2007).


• Bases de datos compartidos del Sistema Nacional de Salud

• Indicadores Sanitarios– Indicadores de nivel de salud– Indicadores estructurales – Indicadores de proceso y de procesos asistenciales compartidos– Indicadores de accesibilidad al sistema– Indicadores de calidad de la atención en el SNS– Indicadores de resultados del sistema – Indicadores de referencia

• Informes periódicos y coyunturales


• Interoperabilidad plena de las tarjetas sanitarias existentes en el SNS

• La informatización de los registros clínicos de cada usuario o paciente (Historia Clínica Digital del SNS

• Receta electrónica. Acceso electrónico a las órdenes de prescripción de medicamentos desde cualquier punto de dispensación del país

• Nodo central de comunicaciones: Telecita y Telemedicina.


-OMI-AP-ABUCASYS

-DIRAYA-DRAGO

-TURRIANO-E.SIAP-IANUS

-OSABIDE-MEDORA

-JARA

HISTORIA CLÍNICA DIGITAL DEL SNS


Red asistencial y docente consolidadaMejor atención clínicaResolutividad altaAmpliación de servicios a la poblaciónTransferencia de servicios del Hospital a Atención PrimariaAprovechamiento de MF en el ámbito hospitalario (urgencias, …)(GPSI).Colaboración o gestión conjunta de casos Promoción y prevención de la salud Práctica familiar Actividades comunitarias Docencia Investigación

FORTALEZAS

VENTAJAS DEL MF COMO REGULADOR DE FLUJOS,

GESTOR DE CASOS Y FUNCIÓN CENTRAL EN EL SISTEMA

FIGURA REQUERIDA PARA OTROS ÁMBITOS,

ADEMÁS DE LA APS


• La Atención Primaria no es la función central real

• Financiación insuficiente• Organización rígida y

burocratizada • Formación de grado poco

orientada a la AP• La efectividad no se mide• La equidad se rompe en sus

extremos: población muy desfavorecida y muy favorecida

• La satisfacción de los profesionales es media-baja

• Incremento de demanda y presión asistencial

• Coordinación mejorable (equipo, médico-enfermera, atención primaria-hospital, gestionados y gestores)

• Proliferación de sistemas de información

• Politización de una gestión descentralizada


El Proyecto AP21 establece un horizonte estratégico de 6 años (2007-2012), para que las Comunidades Autónomas y el MSyC desarrollen las estrategias propuestas.

Este proyecto fue aprobado por el Pleno del Consejo Interterritorial del Sistema Nacional de Salud en su sesión de diciembre de 2006.

1. Estrategias de mejora de la calidad de los servicios orientadas al ciudadano.

2. Estrategias de mejora de la efectividad y la resolución.

3. Estrategias de mejora de la continuidad asistencial.

4. Estrategias de mejora de la participación y el desarrollo profesional.

5. Estrategias de mejora de la eficiencia, gestión y organización.

El Proyecto AP21 consta de 44 estrategias y 201 líneas de actuación, agrupadas en 5 bloques:


1. Mejorar la financiación del sistema sanitario. Incremento del PIB y del % en Atención Primaria

2. Prestigiar el primer nivel sanitario:objetivo clave de los Ministerios de Sanidad y Educación y de las CCAA. Marketing interno y externo.

3. Incrementar el número de médicos en Atención Primaria en relación al total de médicos del SNS. Starfield (50%) o OMS (60%).

4. Desburocratización de la consulta

5. Incrementar la resolutividad de la Atención Primaria.

6. Profundizar y generalizar las reformas procoordinación entre niveles y sectores

7. Mejorar la formación de medicina de familia en el grado

8. Mejorar la formación de los especialistas del segundo nivel en MFyC y en Atención Primaria.

9. Potenciar la investigación en Atención Primaria.

Conclusiones


Daily work in the office: GP, PA, PN/NP

• Regular consultations (~ 35 pts/day; 5-20 minutes pp)Regular consultations (~ 35 pts/day; 5-20 minutes pp)

• Home visitsHome visits

• Diagnostic procedures (ecg, spirometry, tympanometry)Diagnostic procedures (ecg, spirometry, tympanometry)

• Minor surgeryMinor surgery

• Emergency careEmergency care

• Preventive medicine (vaccination, cervical smears)Preventive medicine (vaccination, cervical smears)

• Chronic care (DMt2, COPD)Chronic care (DMt2, COPD)


Key figuresKey figures

• Population: 16 millionPopulation: 16 million

• Life expectancy (2005): 77 (M), 82 (F)Life expectancy (2005): 77 (M), 82 (F)

• Population consulting GP’s annually: Population consulting GP’s annually: 75% (90% in 3 years)75% (90% in 3 years)

• Health expenditure per head: 9,4% BNI Health expenditure per head: 9,4% BNI (€ 50 mlj)(€ 50 mlj)


Healthcare costs in Europe (% of BNI)© RIVM Bilthoven


Medical professionsMedical professions

• General practioners• Med. Specialists• Public health doctors• Nursing home doctors• Pharmacists• Midwives• Physiotherapists• Nurses• Practice assistents

8.400

18.000

3.900

900

2.250

1.300

14.000

320.000

20.000


Features of Dutch GP care (1)Features of Dutch GP care (1)

• Practitioners• Parttime workers• Division by sex• Practices

8.400 (27% single handed) 62% 35% female 4.500 practices

50% single handed 30% duo20% group practice 8% pharmacy



• Practice size• Direct acces• 24 hrs-7days/wk• GP for all pts• Patient contacts

• Computers

2.331 inhibitants/GP Same day, no waiting lists After-hours GP units 99% is listed with a GP 35 pts/day, 2-3 home visits 5-20 min/consultation 99% EMD, electronic

prescription system



• Gatekeeper systemGatekeeper system• 6 contacts per patient per year6 contacts per patient per year• > 90% of all complaints treated by GP’s> 90% of all complaints treated by GP’s• Referral rates: in 4% of contactsReferral rates: in 4% of contacts• Prescription rates: in 2 out of 3 contactsPrescription rates: in 2 out of 3 contacts• 4% of total health care budget4% of total health care budget


Basic values of primary careBasic values of primary care

General: all people and health problems Accessible: easy, close by, 24/7 Personally: individual, environment

Continuous: all stages of life and diseases


Quality AssuranceQuality Assurance

Recertification

Criteria:• Every 5 years• Working as a GP• CME (40 hrs/yr)• Out-of-hours care


Dutch College (NHG) (1)Dutch College (NHG) (1)Focus: Scientific support of GP in daily work Internal motivation Ownership

Membership 95% Staff: 65 fte./130 people Finance: membership fee (75%)

insurence comp (15%)projects (10%)


Dutch College (2)Dutch College (2)

Guideline development since 1989130 guidelines (reg. updated)

Implementation programmepat.information, CME, ICT etc.

Accreditation of practices (NPA)


Basic values of guideline Basic values of guideline developmentdevelopment

Evidence Based MedicineIn doubt: abstainNatural course is of major importanceNon-medicinal advice is preferred

above medicinal interventionNew drugs must demonstrate clear

advantagesPreference for primary over sec. care

(provided equal results)


Dutch College Dutch College ((33))

Quality assurance

Practice Accreditation


Practice Accreditation

Characteristics

Three year cycleThree different domains:

- Practice management- Medical performance- Experiences of patients (EUROPEP)


Improvement plans

Based on feedback reportTopics from three domains:

– Practice management

– Medical performance

– Experiences of patients


Audit

Review of the improvement plans Minimum requirements Audit 2nd and 3d year:

Did the practice succeed?What about the next plan?


Health care financing

• Basic insurance for non-catastrophic risks: ± 1200 € insurance per patient Free GP-care, no threshold Free hospital care; threshold payment (150 euro)

• Private insurance for dentist, FT, special care (> 70 % of all insured)


GP financing

• Payment system All patients insured for GP Basic: 65€ pp/y (GP + NP) Consultation: 9€/10 min. Home visit: 13.50€ 25 – 75€ incentive for: ECG,

spirometry, minor surgery, etc


Current Issues• Changing needs and demands of patients

Gate keeping Call for private care Internet

• More demand of transparency• Market oriented approach• Categorization of care• Financial issues (primary vs secondary care)• Influence of farmaceutical industry


The Swiss Health System

• „27 health care systems“ - each canton + 1 national– Healthcare is a domain of the cantonal government

• mostly privately organized practices• cantonally and privately organized hospitals

– most with outpatient practices and emergency ambulatories

• 92 health insurance providers – mandatory for every person– problem of a rising number of non insured people - 5% - by not paying the

fees

• „Tiers payant / garant“ coexist even in the same insurance– Tiers payant: Health Insurances pay the bill to the doctor, patients get a bill

from the insurance for their agreed participation in the costs– Tiers garant: Patients pay the bill to the doctor, then get the money back

from the insurance company minus the agreed participation in the costs


GP‘s in Switzerland

• About 6000– Most of them with a specialty title after more then 5 years of little

structured vocational training: 2/3 with a title of GP/FM, 1/3 of internal medicine

– a common title is carefully discussed but not at all easy to introduce

• Most in 1-2 physician private practice– few HMO-practices– rising number of big private practices in town and country

– 1-2 GPs, 1-2 Medical Practice Assistants, 1-2 Apprendices


GP‘s in Switzerland

• Visits: average 25-30 patients a day (up to 50)

• With / without pharmacy– regulated by the cantons: ~50% with compulsory prescription-only service, ~50% with

direct sale of drugs; – some cantons with mixed systems

• town with pharmacy • country without pharmacy

• Smaller or larger lab– Haematology, Chemistry, Urinalysis; special analyses are outsourced with well

organized pick up services by big laboratories; even for emergencies

• X-Ray (offered by most), Ultrasound (offered by few)


EPR in Switzerland(electronic patient record)

• Over 80% of GP with paper based patient records– ~ 100% with electronical administration

• Obstacles– High financial investment and costs

• about 60‘000 € per GP, TCO – total costs of ownership in 5 years– Data loss– Disturbance of the doctor-patient-relationship– Dependence on eletronics, technique, support– missing data transfer between different EPR-systems

• No governmental financial incentives


Billing

• Fee for duty based on time

• Each act is charged with a „time-weight“ by steps of 5 min– consultations flexible corresponding to the real time spent with the patient– X-Ray, laboratory, ECG etc charged additionally at a fixed price each

• Patient (tiers garant) or insurance company (tiers payant) gets and pays the bill (on paper!)

• Franchise CHF 300, 600 ore more depending on the policy fee

• Cost sharing of 10% of the costs, max CHF 700/y

• GP is payed by patient or insurance company– loss for the GP resulting from bills never payed by patients < 3 %

• Income ~100‘000 – 150‘000 €/year


Finnish Health Care System

Mikko ValkonenMD

Chair of the General Practicioners in Finland GPF


History in Short

• 1940 Maternal and Child Care Clinics

• 1950-1960 Local and Central Hospitals

• -90% of doctors recruited in hospitals

• -preventive care was lacking: increase in cardiovascular disease

• 1970-1980 Building of Primary Health Centres


Building of Primary Health Centres

• Started in the north and east• Run locally by the municipalities (470)• Money given by the state up to 75% of the costs• Wide range of services:• -GP services• -Maternity and child welfare• -Dental care• -School health care• -Long term inpatient care


Building …

• New Medical Schools were established

• ( Helsinki, Turku, OULU,KUOPIO,TAMPERE )

• Ca 700 med students 7 year

• Number of physicians tripled in PHC

• 3548 physicians, 64.3 % female


Physicians in Total

• 16287 working physicians, of which

• 7716 in hospitals (47,4 %)

• 3548 in health centres (21,8 %)

• 1800 in private practise (11,1 %)

• 1016 in occupational health care (6,2 %)

• 917 in research and teaching ( 5,6 %)

• 1290 in other medical duties (7.9 % )


Physicians in working age

• Total 19020• In Finland 17796• Density varies• In cities and surroundings with medical

schools: 215-246 inhabit./physician• Remote regions 400-565 inhabit./physician• Lack of physicians in PHC: remote areas

and big cities, total 11% of vacancies


Physicians…

• 651 finnish physicians working abroad• 268 in Sweden• 73 in USA• 61 in Germany• 47 in Great Britain• 36 in Norway• 19 in Switzerland• 147 elsewhere


Physicians….

• Physicians of foreign nationality working in Finland

• 179 Estonians• 95 Russians• 51 Germans• 17 Polish• 10 Spanish• 7 English• 181 Other nationalities


PHC sytem in Finland

• Municipal health care system• Municipalities legally obliged to organize

adequate health services to their residents• 348 municipalities currently• Mean population less than 6000 inhabitants• Municipalities levy taxies (16-24%) of income to

fund these services• State subsidies given to municipalities according

the wealthiness.


PHC contd

• Municipality can have a health centre of it´s own or together with other municipalities ( federation)

• Municipality is run politically by municipality boards elected every 4th year.

• Municipality board makes the budget and decides the taxation % each year.

• Municipality board elects the HEALTH BOARD consisting of politicians, which runs the health care ( both primary and secondary health care)


Secondary health care

• Each municipality must belong to a Hospital District to arrange specialist health care.

• Hospital districts are owned financed by the municipalities

• There are 20 hospital districts with population varying from 65.000 to 1.4 million inhabitants

• 5 of the hospital districts are university hospital districts with a central university hospital


Municipal And Parallel Systems

• Municipal primary and specialized health care

• Occupational health care

• Private health care


Municipal health care

• Each municipality is free to determine its own scope of services when exceeding the minimum national coverage standards

• Range of services:• Preventive care: 11-15 antenatal care visits for pregnant

women, regular check-ups for all children 0-6 yrs with immunization programme

• School health care 7-16 yrs, studying health care 16-? Yrs• Preventive antenatal and curative dental care 0-? Yrs• Rehabilitation, ADL-aids ( Health centre wards )• Short term in-patient care ( Health centre wards)• Long term care ( health centre wards, sheltered wards )


Municipal..

• GP outpatient clinics• 1-18 GPs working in the same premises• Approx 2000-2700 inhabitants per GP• Scheduled appointments• On call –appointments• Usually open 8 a.m. 4 p.m. Mon-Fri• Other times referred to centralized doctor-in-duty• Working with health care nurse especially with long-term

illnesses ( diabetes, asthma, hypertension etc. )• .Once-a-year check up with the GP with chronic illnesses


Municipal…

• Clinical guidelines• Medical Society Duodecim in cooperation with various

medical speciality associations has issued the National Current Care Guidelines

• Procedural standards based on the best possible evidence on health and cost outcomes

• Devised in working groups comprised of Finnish experts in the relevant field

• 80 guidelines ready for different dieseases and medical conditions

• Also a patient version called ”Health Library”


Municipal health centres

• Variety of expertise: midwives, nurses, public health nurses, physiotherapists, dietists, podologists, logopeds, psychologs, social workers, pharmaceuts, laboratory nurses, x-ray nurses, dental nurses, dentitsts, oral hygienics

• Internal referrals required for physiotherapy, laboratory, x-ray, logopedist.


Health centres…

• 70% of all outpatient visits• 60% of dentists visits• 95% of inpatient care• Fees cover 7% of the costs• State subzides ca 25% of the costs• (Range 0,0-2500 € / resident/year )• Rest covered by the municipal taxation (25% of all

municipal taxes go to health care )• Mean 1300 euros / inhabitant, range 940-2500 €


State subsidiariescalculation

• Number of inhabitants (/sq km )

• Age structure of the population in the municipality

• Unemployment rate

• Remoteness

• Morbidity in the municipality


Funding for health care

• Health care budgets based on previous allocations• In federation-ownned health centres the same way, but costs

distributed by the actual volume of services used by the inhabitants in each municipality

• Hospital districts make contracts with municipalities how to finance their budget and costs aredistributed by the actual volume of services used by the inhabitants in each municipality

• Funding for exceptionally high costs that exceed 50.000 euros /patient / year

• Hospital district invoicing and pricing are in continious change and varying from district to district .


Health centres..

• Full scale laboratories send specimens for examination

• Some frequent tests made in HC lab, most sent to big laboratories, costs effectiveness

• X-ray units in almost all HC, ultrasound• Audiograms, spirometries. Electrocardiograms,• Gastroscopies, colonoscopies in some• Minor operations• Deliveries in remote areas


Use of Measurement Data

• Use of performance measures in health care management is essentially non-existent

• Health outcomes not routinely used

• Purchaser-provider -split

• Some private quality and outcome indicators ( Hypertonia, diabetes, asthma) spread to health centres



• Targets to follow-up by municipalities to improve their health care:• Consumption of alcohol• The proportion of overweight people in working age• The proportion of smokers• The functional capacity of the elderly people• The number of home and recreational accidents• User satisfaction in health and social care• Maximum waiting times• Shortage of physicians and dentists in PHC• Geographical differences in the effectiveness of secondary health care



• A wide variety of registries is routinely collected from different sectors of society

• Each includes an individual´s personal identification number

• The data from various sources can be linked at the level of the individual

• The PERFECT –project: To systematically monitor the effectiveness, quality and cost-effectiveness of care cycles in specialized medical care across regions, hospitals and population groups. ( Stroke, hip fracture, low bith-weight infants,breat cancer,schizophrenia,acute myocardial infarction, revascular procedures, hip and knee replacements )


Registers

• Register on causes of death• Cancer register• Hospital discharge register• National health insurance register• Health care activity statistics• Statistics on private health care• Annual survey on health behaviour and health

among the Finnish adult population• Random, 5000 aged 15-64 yrs, since 1978


Health Infarmation Technology

• Most health providers use electronic patient information systems

• Decentralization: Ununiform, non interoperable information systems even within a single health care organization

• Lack of information technology standards until 2006• New system under development, fully in function 2011• Patient record archives will be stored in a single system

maintainned by the Social Insurance Institution• Obliged to the public providers of health care• Private providers are required join the system if they

already have electronic archives


Health Information Technology

• Acess to system by index service

• Patient´s cosent is needed to acces another provider´s records

• Individuals have acces to their own records

• Individuals have information about who has accessed their records and when their records were accesed


Electronic prescription

• All providers are obliged to write prescriptions electronically in 2011

• Patients are free to refuse electronic presription and recieve a cnventional paper prescription instead

• National database, electronic access by pharmacies


Electronic health information

• Portal ”Terveysportti” in 2000 by Duodecim-society• EBM Guidelines• Current Care Guidelines• Drug charasteristics and prices• Cochrane Library• ICD 10 codes• Two leading Finnish medical journals• Several leading international medical journals• Portal ”Terveyskirjasto” in 2006 for the public• -patient –centric articles concerning diseases and treatments


General satisfaction with primary care

• In rich cities patient satisfaction can be 44% ( Espoo survey 2008 ) in PHC

• In poorer areas and in country side satisfaction can be up to 85%

• Dissatisfied: Contact, waiting times• 30% same day• 30% after a week or longer• Doctor on call: 90% patients waited less than 2

hours


General Satisfaction

• Complaints about the conduct of the personnel

• Usually no complaints of the skills of the personnel

• Non-fault system for adverse events


Doctors´ satisfaction

• Generally satisfied

• Dissatisfaction in big cities

• Too many patients

• Too much clerical work

• Too complicated tasks beyond competence

• Money can´t pay


Satisfaction increases

• Less out of hours work

• Amount of work

• Alternative working forms

• -hiring companies

• -better wages

• 70% of new doctors female

• Retiring age increases to 63 yrs


THE ESSENTIAL FEATURES OF BRITISH GENERAL PRACTICE

• NATIONAL HEALTH SERVICE

• FUNDED THROUGH GENERAL TAXATION

• SERVICE FREE AT POINT OF ACCESS

• MINIMUM CO-PAYMENTS, E.G.

PRESCRIPTION CHARGES


ESSENTIAL FEATURES

99% OF POPULATION IS REGISTERED WITH A GENERAL PRACTITIONER

ON AN AVERAGE DAY THERE ARE 1 MILLION GP CONSULTATIONS AND 1.5 MILLION PRESCRIPTIONS ISSUED

ABOUT 90% OF ALL HEALTH NEEDS IN BRITAIN ARE MANAGED IN PRIMARY CARE

GENERAL PRACTICE IS THE MOST COST EFFICIENT PART OF THE NHS


ESSENTIAL FEATURES

• INTERNATIONAL COMPARISONS SHOW IT IS BOTH CLINICALLY AND COST-EFFECTIVE

• A GP CONSULTATION COSTS €33

LESS THAN:

- A HOSPITAL OUTPATIENT ATTENDANCE

- ATTENDANCE AT AN ACCIDENT DEPARTMENT

- ATTENDANCE AT A WALK-IN CLINIC

• THE ANNUAL COST OF FULL GP CARE FOR A PATIENT IS €104.


PATIENT SATISFACTION

• SATISFACTION WITH GENERAL PRACTICE IS HIGHER THAN FOR ANY OTHER UK PUBLIC SERVICE

• 95% EXPRESS CONFIDENCE AND TRUST IN THEIR GP

• 92% CLAIM THEY ARE TREATED WITH RESPECT AND DIGNITY

• 82% SAY THEIR DOCTOR ATTENDS AND LISTENS CAREFULLY

• 88% SAY THEY ARE INVOLVED IN DECISIONS ABOUT NEW MEDICATION


CORE VALUES

• CARE ORGANISED AROUND A REGISTERED LIST

• PERSONAL CARE FOR THE INDIVIDUAL PATIENT

• BOTH FAMILY AND COMMUNITY ORIENTATED CARE

• LIFE LONG MEDICAL RECORD

• COMPREHENSIVE CARE – BIRTH TO DEATH

• HOLISTIC CARE


CORE VALUES

• HIGH QUALITY

• CARE CLOSE TO HOME

• CO-ORDINATED CARE

- PRACTICE TEAM

- REFERRAL TO SECONDARY CARE

- POST HOSPITAL CARE

- PREVENTIVE CARE


ORGANISATION OF CARE

NUMBER OF PRACTICES 10,759

ONE DOCTOR 21%TWO DOCTORS 19%THREE DOCTORS 14%FOUR DOCTORS 13%FIVE DOCTORS 11%SIX DOCTORS 8%SEVEN PLUS 14%

POPULATION 60 MILLION


WORKING CONDITIONS FOR GPs

CONSULTATION LENGTH – AVERAGE

1992 8.5 MINUTES2006 12 MINUTES

HOURS OF WORK – AVERAGE

44 HOURS / WEEK(EXCLUDES OUT OF HOURS WORK)8.00 A.M. – 6.30 P.M., MONDAY TO FRIDAY


GP CONTRACT

NEW CONTRACT NEGOTIATED FOR 2004

1. ESSENTIAL SERVICES

2. QUALITY AND OUTCOME FRAMEWORK

3. ENHANCED SERVICES


NEW CONTRACT

• IMPROVED GP INCOMES AND PENSIONS

• REDUCED EXCESSIVE HOURS OF WORK

• OUT OF HOURS CARE NOW VOLUNTARY NOT COMPULSORY

• AVERAGE INCOME NOW €133,000 PER ANNUM

• INCREASED RECRUITMENT OF GPs AND DOCTORS TRAINING FOR THE SPECIALITY


NEW CONTRACT

ADVANTAGES FOR PATIENTS

• MORE SERVICES PROVIDED AT GP SURGERIES

• IMPROVED ACCESS FOR PATIENTS, 84% SATISFIED WITH OPENING TIMES

• IMPROVED CONSISTENCY OF CARE THROUGHOUT THE UK THROUGH STRUCTURED MANAGEMENT OF CHRONIC DISEASES


QUALITY AND OUTCOMES FRAMEWORK

IMPROVED CARE THROUGH THE MONITORING AND TREATMENT OF ACUTE AND CHRONIC HEALTH PROBLEMS

NATIONALLY AGREED STANDARDS, BASED ON LATEST RESEARCH EVIDENCE



COPDCORONARY HEART DISEASE

DIABETESASTHMA

HEART FAILUREATRIAL FIBRILLATION

DEMENTIADEPRESSION

STROKE / T.I.A.PALLIATIVE CARE



LEARNING DISABILITIES

HYPOTHYROIDISM

CANCER CARE

EPILEPSY

CHRONIC KIDNEY DISEASE

HYPERTENSION

CHRONIC MENTAL HEALTH ILLNESS

SMOKING STATUS

OBESITY


AN EXAMPLE – DIABETIC CARE

IN UK: 1. HBAIC 7.5% OR LESS IN OVER 70% OF PATIENTS

2. BLOOD PRESSURE CONTROL IN 80% OF PATIENTS

3. APPROPRIATE TREATMENT FOR RENAL COMPLICATIONS IN >90%

IN USA: BEST FIGURES FROM CHICAGO:

HBAIC 8% OR LESS IN 40% OF PATIENTS


ENHANCED SERVICES

NATIONALLY OR LOCALLY AGREED

• MINOR SURGERY

• MINOR INJURIES

• SMOKING CESSATION

• LEG ULCER CARE

• ANTI-COAGULANT MONITORING

• DRUG LEVEL MONITORING

• EXTENDED HOURS


EDUCATION / TRAININGUNDERGRADUATE: 5 YEARS

POST GRADUATE: 2 YEARS PRE-SPECIALIST TRAINING

3 YEARS SPECIALIST TRAINING FOR GENERAL PRACTICETO BE INCREASED TO 5 YEARS

QUALIFICATION: MRCGPREQUIREMENT FOR PRACTICE FOR NEW GPs

ANNUAL APRAISAL5 YEARLY REVALIDATION


PROBLEMSGOVERNMENT APPROACH

1. IMPOSITION OF NEW PROGRAMMES OF CARE WITH INADEQUATE

- EVIDENCE - CONSULTATION- FUNDING

2. RENEGING ON CONTRACTURAL AGREEMENTS, E.G. PENSION ARRANGEMENTS

3. CENTRALLY IMPOSED MANAGERIAL SUPERVISION ON TARGETS NOT RELATED TO PATIENT CARE OR LOCAL NEEDS


PROBLEMS4. DIVERSIFYING CARE WITH NEW CONTRACTS

OFFERED TO PRIVATE COMPANIES TO PROVIDE PRIMARY CARE. UNEQUAL TENDERING PROCESS BASED PRIMARILY ON PRICE NOT QUALITY OF SERVICES

5. POLYCLINICSPLANS TO OPEN LARGE CENTRES THROUGHOUT THE COUNTRYCENTRALISE CLINICAL SERVICES IN ONE LOCATIONTHREAT OF CLOSURE TO LOCAL PRACTICESRELOCATE SECONDARY/SPECIALIST SERVICES FROM HOSPITALS


PROBLEMS

6. RESOURCES FOR GENERAL PRACTICE FROZEN FOR LAST 3 YEARS

7. PERSISTENT GOVERNMENT DENIGRATION OF GENERAL PRACTICE

8. ATTEMPTING TO EXERT MANAGERIAL CONTROL OVER PROFESSIONAL ACTIVITY


THE FUTURE

• CARE REMAINS ORGANISED AROUND THE PATIENT AND THEIR NEEDS

• GPs AT THE CENTRE OF THIS, AS THE PATIENT’S ADVOCATE AND HEALTHCARE PROFESSIONAL IN THE BEST POSITION TO TAKE RESPONSIBILITY FOR PROVIDING, CO-ORDINATING CARE AND ABLE TO SIGNPOST TO APPROPRIATE SERVICE

• QUALITY IMPROVEMENT IN AREAS WHERE THE GAP BETWEEN BEST AND TRAILING EDGE IS MARKED


THE FUTURE

• MANAGERS AND CLINICIANS WORKING TO A COMMON GOAL

• WIDER RANGE AND GREATER PROVISION OF SERVICES IN THE COMMUNITY

• PRACTICES WORKING TOGETHER IN COLLABORATION

• THE HEALTH DEPARTMENT BEING CLEAR ON ITS AIMS AND WILLING TO WORK WITH THE PROFESSION TO DELIVER THEM

• NATIONAL DIRECTION WITH LOCAL FLEXIBILITY


1. TransparencyAccountabilityEBM-guidelines

1

2

2. Flexibility“colloque singulier”

3

3. Population-orientedsystematic prevention

Visentin G. 28/10/2009Isabel CaixeiroUEMO

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Members

• Austria

• Belgium

• Bulgaria

• Croatia

• Czech Republic

• Denmark

• Finland

• Germany

• Hungary

• Iceland

• Ireland

• Italy

• Luxembourg

• Malta

• Norway

• Portugal

• Slovakia

• Slovenia

Spain Sweden Switzerland The Netherlands Turkey United Kingdom

Observer: Lithuania

Visentin G. 28/10/2009Isabel CaixeiroUEMO

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Final reflections

• At EU level there is no harmonization about GP/FP medical speciality (Directive 2005/36/CE)

• Integration of different levels of care remains a problem

• Different and contradictory pathways in primary care reforms (liberalization, private roles, health industry).

• Health reforms rely more on political priorities than answers to policy/technical questions


A public university of excellence specialized in applied sciences (including healthcare management research lead by Mes -

Management & Health Lab.)

In collaboration with Sant’Anna School of Advanced Studies, Pisa

Visit Sant’Anna School of Advanced Studies at: www.sssup.it

and European Forum for Primary Care at: www.euprimarycare.org

The 2010 conference of “The Future of Primary Health Care in Europe III” Pisa, Italy (August 30/31, 2010)

http://www.sssup.it/