Poor communication between primary care, hospitals and medical specialists often results in fragmentation of care, low-quality patient experience and sub-optimal outcomes. The role of primary care in providing improved coordination of care is under debate in many countries with policy in some countries seeking to develop the ‘primary care medical home’, where a family medicine practice assumes full responsibility for the health and care of its enrolled patients, even when they are referred for diagnosis or treatment beyond primary care.
Other factors that are creating a need for change in primary care include: the development of technologies that enable new forms of information, access and involvement for patients; innovative drug treatments and therapies that enable more community and home-based care; and changes in patients’ expectations about access to care and the range of services that should be available to them.
Developments in information technology are also challenging the whole concept of ‘primary care’. For example, electronic health media including the Internet, telehealth and telecare are leading to a significant reappraisal of where a person’s first contact with health advice and support takes place and how health providers can utilize such media and technology to support people’s care.
Healthcare in austerity
In many countries, the global financial crisis has driven cuts in public spending, unpredictable revenue for healthcare, and cuts in other essential services which affect health (eg housing). Maldvosky (2008) notes the challenge of implementing austerity policies while achieving national health goals such as equitable access. Research suggest that in some countries, strengthened primary care is regarded as a critical element of a health system reconfigured to provide care in a time of austerity (ref EHO work).
Variation in policy, regulation and payment systems
There are significant differences in the political and economic contexts in which primary care operates. Former central and Eastern European countries illustrate how differences in national policy, payment systems and regulation have shaped the organization of services and, thus, the starting point for primary care transformation.
For example, in Hungary fee for service payments and regulatory controls on General Practitioners (GPs) grouping together have largely kept GPs in solo practice with few connections with specialists. In Croatia policy to develop universal access to a broad range of primary care services, linked to investment in polyclinics has co-located GPs and specialists, encouraging some collaboration and shared clinical standards.
In contrast, western European economies pursuing competition and market-driven reforms are exploring policies as a way to introduce new primary care providers and to increase competitiveness and drive innovation.
Health and Care services
The variability in what constitutes ‘health’ or ‘social’ care across Europe is another key influence on the role and organization of primary care. The Scandinavian model of strong municipal government creates a system in which polyclinics run by municipalities link health and care provision. This contrasts with the UK, where local government care services have tended to operate separately from the NHS.
Policy on access to generalists and specialists
Policies on issues such as direct access for patients to specialists, primary care gate-keeping, and choice of primary care provider sustain diversity in European primary care.
Policy in the Netherlands to reform chronic disease management illustrates how payment systems can drive new ways of working between GPs and specialists in selected services.
Primary care organizations
As noted previously, the scale and scope of primary care organizations varies across Europe as does the value base underpinning its role within the wider health and care system (see table 2 below). Standalone clinics run by single-handed doctors are typical in some countries, and large health centers run by multi-professional teams including social care, being the norm in others.
Mixed views about smaller clinics
The incentives on self-employed sole-practitioners with fee for service payments may drive over-investigation and over-referral. But research also describes benefits for patients in small practices in terms of greater continuity of relationship. And innovative physicians can take a public health perspective, adapting their services to meet population needs, as seen in the Risiori Rural Clinic, Romania.
Bigger primary care organizations
New models of primary care organization are emerging in countries which are seeking better coordination between services for people with long term conditions and stronger links between primary and specialist care. There is a growing trend towards larger scale practices – working through networks; polyclinics; extended physician partnership or integrated systems.
The strength of these models lies in their scale which allows:
- an extended range of services with access to specialist advice,
- a focus on population health management,
- development of tailored care for people with multi-morbidity,
- peer review and clinical governance,
- professional humans resource, financial and leadership capacity,
- investment in IT and other technologies,
- career development and support for professional and other staff.